1. 19 year old female with arm swelling Steven Shackford, MD FACS 2006

2. 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: a)Set the patient up for your next available appointment—10 days hence. b)Have the patient elevate the RUE— call if swelling does not resolve. c)Refer the patient to an orthopedist d)See the patient today

3. 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: 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.

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

5. You get a venogram

6. Based on this venogram, you: a)Admit the patient for anticoagulation b)Refer to Medicine for admission and anticoagulation c)Initiate lytic therapy d)Admit patient for trans-axillary first rib resection.

7. Lytic therapy successfully opens the subclavian vein, but there is marked effacement at the point where the vein crosses the 1 st 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 1 st rib resection ASAP (this admission). d) Begin anticoagulation with heparin and schedule her for a trans-axillary 1st rib resection ASAP.

8. You elect to proceed with a trans-axillary 1 st 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)

9. First rib resected Still has obstruction SVC fills, but less intensely than the vein

10. 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.

12. Post balloon venoplasty

13. Postoperatively, she does well. You now: a)Discharge her and tell her to follow up with the RN at the student clinic. b)Discharge the patient on coumadin for 3 months. c)Discharge the patient on coumadin and to see you in the office in a month for imaging.

14. Anatomic vulnerability

15. Pathophysiology

16. History l Classical or common * Unusual strenuous effort * Repeated movements associated with work or athletics l Frequent * Old clavicle fracture with hypertrophic nonunion * Situational: back pack use, prolonged position l Uncommon * No contributing etiology * Think hypercoagulable/hypofibrinolytic state

17. Unusual strenuous effort (L) Repeated work effort (R)

18. Athletics

19. Clavicular fracture l Fracture history is remote l Hypertrophic nonunion: otherwise asymptomatic l Intermittent obstructive symptoms not uncommon l Usually an active person

20. Symptoms l ALL will have these to some degree * Acute > subacute > chronic l Swelling: 85-90% l Pain: 75-85% * Heaviness, fatigue, aching l Violaceous discoloration: 35-50% l Paresthesias: 5-10% l Coldness: 0-5%

21. Signs l Swelling (not edema) l Violaceous discoloration l Dilated superficial collateral veins l Tender axillary cord l Normal motor exam l Normal sensory exam * May have allodynia

22. Diagnosis l Physical exam: suggestive * Objective confirmation needed l Duplex (not B-mode): lab dependent * Sensitivity: 75-100% l Limited by scanning window, nonocclusive thrombus * Specificity: 100% l Venography * Gold standard * Allows for potential endoluminal therapy

26. Treatment Rationale l No treatment * Disability: 25% (Hughes E, Int Abs Surg 38:89, 1949) * Pulmonary embolism: 12-35% l Usually > 1 risk factor l Case fatality rate: 10% * SVC syndrome: reported rarely * Venous gangrene l 16 reported cases (Smith B, Ann Surg 201:511, 1985 ) – Amputation: 54% – Mortality: 31%

27. Treatment Continuum l Dependent on acuity l Gangrene: med + surg l Acute: med + lytics +/- surg l Subacute: med +/- lytics +/- surg l Chronic: +/- med +/- surg

28. Venous Gangrene l Limb threatening l Heparin bolus l Thrombectomy of all major branches l Esmarch wrap with vein open & proximal control l Coumadin: INR 3-4

29. Treatment: Acute UE DVT l Early diagnosis imperative * Collaterals form:  lytic efficacy * Lytics for 24-72h l Arm elevation l Heparin bolus: ptt >2-3x control l Coumadin: INR 2-3 for 3 months l Interval stress venography l Timing of 1 st rib resection * Varies: 1 day – 3months

32. axilla chest wall subclavian vein lipoma

33. subclavian artery subclavian vein anterior scalene (cut) 1 st rib brachial plexus

34. lipoma Scalene tubercle

36. Pre-op obstruction Post-lysis

37. UEDVT <10 days old thrombolytics success-no stenosis stress venogram + anticoag x 3 mos 1 st rib rsn success-stenosis - anticoag x 3 mos 1 st rib rsn angioplasty

38. UEDVT > 10 days anticoagulation x 3 months symptomatic stress venogram obstructs with stress 1 st rib resection obstructed consider reconstruction

39. Summary l All UEDVT is secondary * Virchow’s Triad l UEDVT is under-diagnosed l Delay in treatment worsens outcome l Treatment depends on clinical presentation * Acute * Subacute * Chronic