Chapter 123 - Venous TOS Flashcards
Rate of contralateral vein narrowing in vTOS
56-80%
Rate of bilateral thrombosis in vTOS
2-15%
McCleery syndrome first described
1951 McCleery
McCleery syndrome definition
intermittent obstruction of subclavian evin without thrombosis
McCleery syndrome symptoms
1) blue discoloration of arm
2) superficial vein distention
3) swelling
Secondary UE DVT
1) CVC
2) pacemaker wires
3) nephrotic syndrome
4) mediastinal tumours
5) malignancy
6) local surgery or trauma
7) hypercoagulable state
8) renal failure with dialysis
Rate of CVC causing DVT
5%
Rate of PE with UE DVT (all cause not just vTOS)
15-25%
With PM use, risk factors that increase venous stasis
1) number of leads
2) previous temp PM
3) EF < 40%
4) infection
Pathophysiology of secondary UE DVT
Vein wall damage
epidemiology of vTOS
32 years old
usually 20-40’s
equal gender ratio
First rib bypass venous collaterals
pattern of collateral developing around anterior chest wall, shoulder and neck
Rate of venous gangrene due to vTOS
never reported
usually secondary and has to do with malignancy
Duplex challenges in the upper extremity
1) clavicle
2) lung
Duplex sensitivity and spe on detecting UE DVT
sen 81-100%
spe 82-100%
only if color duplex used on top of Bmode
Positioning of arm in venogram for vTOS
90 and 180 degrees
vTOS patients classified based on chronicity
1) acute subclavian-axillary vein thrombosis
2) chronic or recurrent subclavian-axillary vein thrombosis
3) high grade symptomatic subclavian-axially vein thrombosis
Anticoagulation effect on vTOS
40% has residual symptoms or limited recovery
CVC -induced UE DVT
anticoagulation x 3 months after CVC removal
anticoagulation for the entire time that catheter is in place
Patients with contraindication to anticoagulation with UE DVT
1) conservative mgnt (rate of PE is low)
2) SVC filter
Success of urokinase in treated primary subclavian-axillary thrombosis
82%
time frame of thrombolysis from onset of DVT
< 14 days good results
> 14 days still can do but poorer results
benefit of preoperative thrombolysis before surgical decompression of UE DVT
not clear
surgery alone proves beneficial as well
Risk factors for failing thrombolysis of UEDVT
1) overly aggressive balloon angioplasty in past
2) stenting in vein
Post thrombolysis care in vTOS
1) if completion angio shows no external stenosis - 3-6 months anticoagulation
2) if completion angio shows persistent external compression - consider TOS decompression
Rate of venous rethrombosis during waiting period between thrombolysis and TOS release
6-18%
After vTOS thrombolysis and TOS release, veins reconstruction open vs endo key points
1) open increases morbidity
2) endo requires anticoagulation after so maybe better to wait
Post vTOS repair care
physiotherapy x 6 weeks focusing on
1) ROM shoulder girdle
2) function and flexibility of upper cervical spine
3) strengthen scalene muscles
4) stretch trapezius, SCM, levator scapular and pec minor
5) resistance shoulder elevation exercise
Causes of recurrence after vTOS rib resection
1) incomplete first rib removal
2) subclavius tendon incomplete resection
