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AKSİLLO-SUBKLAVİYAN
VENÖZ TROMBOZLARA
YAKLAŞIM
Prof. Dr. Ufuk ALPAGUT
İstanbul Üniversitesi
İstanbul Tıp Fakültesi
Kalp ve Damar Cerrahisi Anabilim Dalı Öğretim Üyesi
1875



1884
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 riski taşır.
Epidemiyoloji


UEDVT mainly refers to thrombosis of the axillary
and/or subclavian veins
Sites of thrombosis
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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
Veins of the Upper Extremity
Veins of the Upper Extremity
most common
site
second most
common site
Patogenez ve Klasifikasyon

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
Malhotra and Punia.
JAPI 2004; 52:237.
Risk Faktörleri

1.
2.
3.
4.
5.
6.
7.
8.
GEN MUTASYONLARI:
Faktör V
Protrombin
Metilen tetrahidrofolat
Redükteaz MTHFR
Protein C eksikliği
Protein S eksikliği
Fibrinojen
Antitrombin III eksikliği
Risk Faktörleri

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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
Risk Faktörleri

1.
2.
3.
4.
5.
6.
7.
8.
9.
DİĞER FAKTÖRLER:
TOS
Ağır efor
Santral venöz kateter
Pacemaker
Travma
Antineoplastik ilaçlar
Oral kontraseptifler
Hormon replasman tedavisi
Sigara kullanımı
Joffe H.V, MD…A prospective registry of 157 patients Circulation, 2004
Joffe H.V, MD…A prospective registry of 157 patients Circulation, 2004
Figure 3. Multivariable logistic regression analysis to identify factors predicting non–CVCassociated UEDVT rather than lower-extremity DVT.
Joffe H V et al. Circulation 2004;110:1605-1611
ÜEDVT da Semptomlar
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Asemptomatik
Omuz ve/veya boyunda rahatsızlık
Kol ve/veya el ödemi
SVC Sendromu
Kola yayılan ağrı (TOS)
Elde güçsüzlük (TOS)
ÜEDVT da Bulgular
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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)
Ayırıcı tanı
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


lymphedema
neoplastic compression of blood vessels
muscle injury
superficial vein thrombosis
PRIMARY THROMBOSIS

divided into two sub-categories
1.
2.
effort thrombosis/Paget Schroetter syndrome
idiopathic UEDVT
I-Effort thrombosis (Paget Schroetter
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
Paget Schroetter Syndrome
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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
.
Sieniewicz B J , McCabe S Emerg Med J
doi:10.1136/emermed-2011-200648
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 axillarysubclavian vein (Paget-Schroetter syndrome)
Urschel H. C. et al.; Ann Thorac Surg 2008;86:254-260
Tedavi
Treatment
include combination of catheter directed
thrombolytic therapy to restore venous patency and
surgical correction of the anatomic abnormality is
the most effective treatment.



Rib, muscle resection
Less stuff
More space
II-Idiopathic UEDVT
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
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
SECONDARY THROMBOSIS
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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
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
Tanısal Görüntüleme
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Dupleks Ultrasonografi
Renkli Doppler Ultrasonografi
Manyetik Rezonans Anjiografi
Sintigrafik inceleme
Kontrast Venografi (altın standart)
Duplex Ultrasound



initial imaging test of choice
non-invasive
high sensitivity and specificity for peripheral UEDVT
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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
Contrast Venography
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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
MRA
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accurate, non-invasive method for detecting
thrombus in the central thoracic veins (i.e..
SVC and brachiocephalic veins)
?availability
?cost
CT
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involves injection of contrast agent
able to detect central thrombus especially in
brachiocephalic veins
can detect the presence of extrinsic vessel
compression
Treatment
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Joffe et al. Circulation 2002; 106:1876.
Kolun elevesyonu
Kola kademeli kompresyon
uygulanması
Antikoagülasyon
Kateter kılavuzluğunda
tromboliz
Trombektomi
Anjiyoplasti ve stent
uygulaması
Torasik çıkışın
dekompresyonu
Vena kava superiyor
filtreleri
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
ÜEDVT TEDAVİ ALGORİTMASI
Anticoagulation
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1.
2.
3.
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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
Trombolitik Tedavi
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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.
Trombolitik Tedavi

1.
2.
3.
En uygun adaylar:
Genç, primer ÜEDVT olan hastalar
Semptomatik VCS’ lu hastalar
Santral venöz kateterin kalması zorunlu
olduğu sekonder ÜEDVT’lu hastalar
Trombolitik Ajanlar
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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.
Thrombolysis

catheter-directed thrombolysis
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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
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active bleeding
neurosurgery within the past 2 months
history of hemorrhagic stroke
hypersensitivity to the thrombolytic agent
surgery within the preceding 10 days
pregnancy
Suction Thrombectomy
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is often used in combination with
thrombolysis
reduces dose and duration of thrombolytic
therapy
subclavian vein thrombosis with
flow through collateral vessels
persistent subclavian vein
occlusion after thrombectomy
recanalization of subclavian vein
after thrombolysis
Prevention/Prophylaxis
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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
Komplikasyonlar
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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
Conclusions
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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

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