AKSİLLO-SUBKLAVİYAN VENÖZ TROMBOZLARA YAKLAŞIM

1. AKSİLLO-SUBKLAVİYAN VENÖZ TROMBOZLARA YAKLAŞIM Prof. Dr. Ufuk ALPAGUT İstanbul Üniversitesi İstanbul Tıp Fakültesi Kalp ve Damar Cerrahisi Anabilim Dalı Öğretim Üyesi

2. Paget ve Von Schrötter tarafından tarif edilmiştir. Patofizyolojisi ve etiyolojisi alt ekstremite trombozlarına benzer. İnsidans daha düşüktür → %2/DVT (hidrostatik basıncın düşük, venöz valvüllerin daha az sayıda, kan akım oranının daha yüksek ve üst ekstremitelerin daha mobil olması) %10 PTE riskitaşır. • 1875 • 1884

3. Epidemiyoloji • UEDVT mainly refers to thrombosis of the axillary and/or subclavian veins • Sites of thrombosis • subclavian vein (18-69%) • axillary vein (5-42%) • internal jugular vein (8-29%) • brachial vein (4-13%) • often multiple veins involved • rarely bilateral Hylton VJ,et al.Circulation 2002;106:1874-1880

4. Veins of the Upper Extremity

5. Veins of the Upper Extremity most common site second most common site

6. PatogenezveKlasifikasyon • Virchow’s Triad • damage of the vessel wall (endotel hasarı) • alterations in blood flow (staz) • hypercoagulability • UEDVT is classified based on pathogenesis as primary or secondary thrombosis Malhotra and Punia. JAPI 2004; 52:237

7. Malhotra and Punia. JAPI 2004; 52:237.

8. Risk Faktörleri • GEN MUTASYONLARI: • Faktör V • Protrombin • Metilen tetrahidrofolat • Redükteaz MTHFR • Protein C eksikliği • Protein S eksikliği • Fibrinojen • Antitrombin III eksikliği

9. Risk Faktörleri • EDİNSEL FAKTÖRLER: • Kanser • Kalp yetersizliği • Hamilelik • Antifosfolipid sendromu • Nefrotik sendrom • Karaciğer hastalığı • Dissemine intravasküler koagülasyon • Sepsis • Vaskülitler • Heparine bağlı trombositopeni • Yaş • Hipertansiyon • İmmobilizasyon • Geçirilmiş cerrahi girişimler

10. Risk Faktörleri • DİĞER FAKTÖRLER: • TOS • Ağır efor • Santral venöz kateter • Pacemaker • Travma • Antineoplastik ilaçlar • Oral kontraseptifler • Hormon replasman tedavisi • Sigara kullanımı

11. Joffe H.V, MD…A prospective registry of 157 patients Circulation, 2004

12. Joffe H.V, MD…A prospective registry of 157 patients Circulation, 2004

13. Figure 3. Multivariable logistic regression analysis to identify factors predicting non–CVC-associated UEDVT rather than lower-extremity DVT. Joffe H V et al. Circulation 2004;110:1605-1611

14. ÜEDVT da Semptomlar • Asemptomatik • Omuz ve/veya boyunda rahatsızlık • Kol ve/veya el ödemi • SVC Sendromu • Kola yayılan ağrı (TOS) • Elde güçsüzlük (TOS)

15. ÜEDVT da Bulgular • Supraklavikular matite • Palpe edilebilen kord şeklinde venöz yapı • Kol ve elde ödem • Ekstremitede siyanoz • Cilt venlerinde dilatasyon • Juguler venöz dolgunluk • Brakiyal pleksusta hassasiyet (TOS) • El veya kolda atrofi (TOS) • Pozitif Adson testi (TOS)

16. Ayırıcı tanı • lymphedema • neoplastic compression of blood vessels • muscle injury • superficial vein thrombosis

17. PRIMARY THROMBOSIS • divided into two sub-categories • effort thrombosis/Paget Schroetter syndrome • idiopathic UEDVT

18. I-Effort thrombosis (PagetSchroetter syndrome) • Compression of the subclavian vein between the clavicle and the subclavius muscle anteriorly and the first rib and scalenus muscle posteriorly. Demondion X et al. Radiographics 2006;26:1735-1750 AS = anterior scalene muscle, BP = brachial plexus, C = clavicle, CC = costoclavicular space, IT = interscalene triangle, MS = middle and posterior scalene muscles, Pmi = pectoralis minor muscle, RP = retropectoralis minor space, SA = subclavian artery, SM = subclavius muscle, SV = subclavian vein

19. Paget Schroetter Syndrome • usually involves the dominant arm • occurs in young and healthy individuals • associated with physical activities that involve abduction of the upper extremity • pathogenesis • exertion causes microtrauma to the vessel intima and leads to activation of the coagulation cascade • thoracic outlet obstruction is initially intermittent and positional but repeated trauma can result in scar tissue that will compress the vein persistently

20. . Sieniewicz B J , McCabe S Emerg Med J doi:10.1136/emermed-2011-200648

21. Congenital abnormal lateral insertion of the costoclavicular ligament on the first rib with hypertrophy of the scalenus anticus muscle lateral to the vein and thrombosis of the axillary-subclavian vein (Paget-Schroetter syndrome) Urschel H. C. et al.; Ann Thorac Surg 2008;86:254-260

22. Tedavi Rib, muscle resection Less stuff More space • Treatment include combination of catheter directed thrombolytic therapy to restore venous patency and surgical correction of the anatomic abnormality is the most effective treatment.

23. II-Idiopathic UEDVT • patients have no known trigger or obvious underlying disease • often associated with occult cancer • Girolami et al. Blood Coag Fibrinol 1999;10:455-457. • one fourth of patients were diagnosed with cancer within one year of follow-up • prevalence of hypercoagulable states is uncertain • yield of testing is highest if idiopathic DVT, positive family history and recurrent DVT/pregnancy loss

24. SECONDARY THROMBOSIS • accounts for most cases of UEDVT • develops in patients with central venous catheters (CVCs), pacemakers or cancer • majority of patients (33-60%) are asymptomatic • fewer than 3% of patients with CVCs and pacemakers develop clinically evident UEDVT

25. Catheter-Induced Thrombosis • incidence of UEDVT increases in cancer patients who have CVCs (up to 30% of patients) • pathogenesis • vessel wall may be damaged during CVC insertion and during infusion of medication • CVC may impede blood flow through vein and cause areas of stasis • patients with incorrectly placed CVC are more likely to develop DVT

26. Tanısal Görüntüleme • Dupleks Ultrasonografi • Renkli Doppler Ultrasonografi • Manyetik Rezonans Anjiografi • Sintigrafik inceleme • Kontrast Venografi (altın standart)

27. Duplex Ultrasound • initial imaging test of choice • non-invasive • high sensitivity and specificity for peripheral UEDVT • Prandoni et al. Arch Intern Med 1997; 157:357-362 • sensitivity of 96% & specificity of 93% • acoustic shadowing from clavicle will limit visualization of short segment of subclavian vein • look for non-compressibility, intraluminal thrombus and flow abnormality

28. Contrast Venography • procedure involves injection of iodinated contrast in the antecubital vein or distal arm vein • venous anatomy is well-demonstrated • may be technically difficult • should only be used if suspicion for clot remains high despite a negative ultrasound • is required for some interventions and to assess response to treatment

29. MRA • accurate, non-invasive method for detecting thrombus in the central thoracic veins (i.e.. SVC and brachiocephalic veins) • ?availability • ?cost

30. CT • involves injection of contrast agent • able to detect central thrombus especially in brachiocephalic veins • can detect the presence of extrinsic vessel compression

31. Kolun elevesyonu Kola kademeli kompresyon uygulanması Antikoagülasyon Kateter kılavuzluğunda tromboliz Trombektomi Anjiyoplasti ve stent uygulaması Torasik çıkışın dekompresyonu Vena kava superiyor filtreleri Treatment Joffe et al. Circulation 2002; 106:1876.

32. Diagram shows the optimal filter position, with the filter legs immediately below the confluence of the brachiocephalic veins. Spence L D et al. Radiology 1999;210:53-58

33. ÜEDVT TEDAVİ ALGORİTMASI

34. Anticoagulation • cornerstone of therapy • cost-effective • will not recanalize vein but will: • Prevent clot propagation • Facilitate maintenance of venous collaterals • Help to prevent PE • unfractionated heparin or LMW heparin as a bridge to warfarin • warfarin with a goal INR of 2.0-3.0 to be continued for a minimum of 3 months • warfarin for at least 6 months if a coagulation abnormality is detect

35. Trombolitik Tedavi • Tromboliz venin açıklığını daha erken sağlar, damar endoteline hasarı en aza indirir • Uzun dönemdeki komplikasyonların gelişme riskini azaltır (post trombotik sendrom) • En geç semptomların başlangıcından itibaren birkaç hafta içinde uygulanmalıdır, çünkü daha sonra trombüs organize olur ve tedavinin etkinliği azalır. • Kateter kılavuzluğunda tromboliz, sistemik trombolizle karşılaştırıldığında daha düşük dozlarla, daha az kanama riskiyle, daha yüksek oranlarda trombüste tam rezolüsyonu sağlar.

36. Trombolitik Tedavi • En uygun adaylar: • Genç, primer ÜEDVT olan hastalar • Semptomatik VCS’ lu hastalar • Santral venöz kateterin kalması zorunlu olduğu sekonder ÜEDVT’lu hastalar

37. Trombolitik Ajanlar • Ürokinaz • Streptokinaz • rtPA (trombolitik ajan rekombinant doku plazminojen aktivatörü • Anjiojet gibi cihazlarla perkütan mekanik trombektomi cihazları trombolitik tedavi ile birlikte kullanılarak hızlı bir şekilde büyük miktarlarda trombüs çıkarılabilmekte ve böylelikle trombolitik tedavinin dozu ve süresi azaltılabilmektedir.

38. Thrombolysis • catheter-directed thrombolysis • achieves higher rates of resolution with reduced risk of bleeding • rtPA used as a continuous infusion of 1-2mg/h for at least 8 hours • heparin is given concurrently • contraindications to thrombolysis • active bleeding • neurosurgery within the past 2 months • history of hemorrhagic stroke • hypersensitivity to the thrombolytic agent • surgery within the preceding 10 days • pregnancy

39. Suction Thrombectomy • is often used in combination with thrombolysis • reduces dose and duration of thrombolytic therapy

40. subclavian vein thrombosis with flow through collateral vessels

41. persistent subclavian vein occlusion after thrombectomy

42. recanalization of subclavian vein after thrombolysis

43. Prevention/Prophylaxis • tartışmalıdır • mini-dose of warfarin 1mg OD for cancer patients with CVCs • LMW heparin in patients with liver dysfunction or malnutrition Hylton VJ,et al.Circulation 2002;106:1874-1880

44. Komplikasyonlar • ÜEDVT lu hastaların 1/3’ünde PE gelişir. • Ancak nadiren tekrarlar veya ölümcül seyreder. • Sekonder ÜEDVT gelişen hastalarda önemli bir noktada kateterin çekilirken, oluşan fibrin kılıfın kateterden ayrılarak emboliye neden olmasını engellemektir. • Posttrombotik sendrom gelişebilir (kalıcı venöz tıkanıklığa bağlı venöz HT). (%20-100) • Vena kava superior sendromu gelişebilir. • Torasik kanalda tıkanma, brakiyal pleksopati. Malhotra and Punia. JAPI 2004; 52:239

45. Conclusions • UEDVT is a significant cause of morbidity and mortality • incidence is increasing especially in cancer patients with CVCs • UEDVT can be classified as primary or secondary • diagnostic investigation of choice is duplex ultrasonography • anticoagulation (for 3-6 months) is the cornerstone of treatment