Imaging in Deep Venous Thrombosis of the Upper Extremity
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There are 2 forms of upper-extremity deep venous thrombosis (DVT): effort-induced thrombosis (Paget-Schroetter syndrome) and secondary thrombosis. [1, 2, 3] Effort-induced thrombosis, or Paget-Schroetter syndrome, accounts for 25% of cases. [4] Paget in England and von Schroetter in Germany independently described effort thrombosis more than 100 years ago. In this primary form of the disease, an underlying chronic venous compressive abnormality caused by the musculoskeletal structures in the costoclavicular space is present at the thoracic inlet and/or outlet. In 75% of patients with secondary thrombosis, hypercoagulability and/or indwelling central venous catheters are important contributing factors. In fact, with the advent of central venous catheters, upper-extremity and brachiocephalic venous thrombosis has become a more common problem. [5, 6, 7, 8]
Ultrasonography is the imaging modality of choice. Real-time ultrasonography and color flow Doppler imaging are rapid, noninvasive means for the diagnosis of DVT. The lack of full compressibility, the absence of color flow signal and augmentation, and visualization of thrombus are used to make the diagnosis. Upper-extremity venous thrombosis can be diagnosed with color flow duplex imaging with a sensitivity of 78-100% and a specificity of 90-100%. [9, 10, 11, 12, 13, 14]
The central veins cannot always be accurately imaged sonographically; therefore, contrast-enhanced venography remains an important diagnostic tool. In the assessment of effort-induced thrombosis, venographic views include abduction, external rotation, and extension views.
The strength of magnetic resonance venography is in the evaluation of the central veins of the chest; the subclavian vein; the brachiocephalic vein; and the superior vena cava, an area poorly visualized with ultrasonography. Thrombosis is diagnosed as a filling defect in the vessel. [15]
(See the images below of DVT in upper extremities.)
In a study by Kleinjan et al, an algorithm consisting of D-dimer testing, clinical decision score, and ultrasonography safely and effectively excluded upper extremity DVT. [16]
Plain radiographic findings of a clavicle or first rib fracture or presence of a cervical rib can increase the suspicion of thoracic outlet syndrome and venous thrombosis. (See the radiographic images below.)
CT is readily available and widely used. Upper-extremity and central venous thrombosis is often incidentally diagnosed on contrast-enhanced CT scans of the chest. The thrombus is hypoattenuating compared with the hyperattenuating vein.
This cross-sectional imaging modality provides excellent information about soft tissue structures (eg, tumor, lymphadenopathy) surrounding the vein that may account for the thrombosis.
(See the CT images below.)
Patients with effort-induced thrombosis should undergo bilateral upper-extremity venography with provocative maneuvers.
For patients with renal insufficiency or allergy to contrast material, carbon dioxide and gadolinium-based materials are alternative contrast agents for venography. These agents can be used for diagnostic venography and for guiding catheter-directed thrombolysis.
Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.
Patients are positioned with their arm in the neutral, extended, and hyperabducted positions. The diagnosis is made when an intraluminal filling defect is seen or when a deep venous structure does not fill and collateral veins are visualized.
The compressive features seen with provocative maneuvers during contrast-enhanced venography can occur in asymptomatic patients; therefore, not all patients with venous compression have venous thrombosis.
(See the images below.)
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[Guideline] Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e351S-418S. [Medline]. [Full Text].
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Kleinjan A, Di Nisio M, Beyer-Westendorf J, Camporese G, Cosmi B, Ghirarduzzi A, et al. Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med. 2014 Apr 1. 160(7):451-7. [Medline].
Craig Greben, MD Associate Professor of Radiology, Hofstra University School of Medicine; Chief, Division of Vascular and Interventional Radiology, North Shore University Hospital
Craig Greben, MD is a member of the following medical societies: Society of Interventional Radiology
Disclosure: Nothing to disclose.
Hearns W Charles, MD Assistant Professor of Radiology, New York University School of Medicine; Attending Physician, Division of Vascular and Interventional Radiology, Department of Radiology, New York University Medical Center
Hearns W Charles, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Society of Interventional Radiology, Radiological Society of North America
Disclosure: Nothing to disclose.
Jason J Naidich, MD, MBA Associate Professor and Chair, Department of Radiology, Hofstra North Shore-LIJ School of Medicine at Hofstra University
Jason J Naidich, MD, MBA is a member of the following medical societies: American Association for Physician Leadership, American College of Healthcare Executives, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Long Island Radiological Society, New York State Radiological Society, Radiological Society of North America, Society of Chairs of Academic Radiology Departments, Society of Computed Body Tomography and Magnetic Resonance
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine
Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society
Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.
Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System
Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America
Disclosure: Nothing to disclose.
Anthony Watkinson, MD Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK
Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, Royal College of Surgeons of England
Disclosure: Nothing to disclose.
Imaging in Deep Venous Thrombosis of the Upper Extremity
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