Risk Stratification And Incidence Of Acute Complications In Upper

Report
Risk stratification and incidence of acute complications
in upper extremity deep vein thrombosis (UEDVT)
patients.
Dr. Santosh Yatam Ganesh MBBS, MPH.,
Mentors: Dr. Khalid J. Qazi MD, MACP.,
Dr. Paul Anain MD, FACS.
VI.XII.MMXIII
Overview of the presentation
• Purpose of research
• Epidemiology
• Introduction to Upper extremity deep vein thrombosis
(UEDVT)
• Research design
• Results
• Discussion
• Conclusion
Purpose of research
• To understand the risk factors of the UEDVT;
• To identify complications rate due to UEDVT
during the hospital stay;
• This study will help optimize patient care and
decrease the incidence of UEDVT;
Epidemiology
• Annual incidence is 0.4-1 per 10,000 people;
• Of all the deep vein thrombosis cases, nearly 10% involve upper
extremity;
• Incidence increasing;
– Peripherally inserted central catheter(PICC),
– Central venous catheter(CVC),
– Malignancy.
• Complications are rare;
– Pulmonary embolism,
– SVC syndrome,
– Post thrombotic venous insufficiency.
Introduction to Upper extremity deep
vein thrombosis (UEDVT)
• Defined as a thrombus in any of the upper
extremity deep veins.
• Deep veins of upper extremity: Radial, Ulnar, Brachial,
Axillary, Subclavian, Internal Jugular.
• Superficial veins of upper extremity: Digital, Metacarpal,
Cephalic, Basilic, Median.
Primary
•
•
•
Venous thoracic outlet
syndrome,
Effort-related thrombosis
(Paget–Schroetter syndrome) or
Idiopathic.
Secondary
•
•
•
PICC,
CVC,
Malignancy.
• The Computerized Registry of Patients with Venous
Thromboembolism (RIETE):
–
–
–
–
Multicenter study involving Spain, France, Italy, Israel, Argentina
Data released by CHEST in 2008
11564 total. 512 had UEDVT.
Significant findings compared to lower extremity DVT:
• younger age,
• Lower BMI,
• association with Cancer,
• higher overall mortality.
– Also more association with PE compared to without UEDVT.
• 9% had PE
•
•
•
•
•
•
•
•
•
At University of California
Recent article
One year study
Out of 373 patients underwent Ultrasound 94 had DVT
Mean age 51
46(49%) had malignancy
Pain swelling common symptoms
11 patients had PE
Subclavian : most common vein
• One year data from 12 hospitals.
• Total 483. Out of which 69 had UEDVT
UEDVT
LEDVT
16 per 10,000
71 per 10,000
AGE: 59
66
• Significantly associated with Central lines, ICU admissions
• No difference in 30 days, 6 months and 1year outcomes
• No statistical difference in association to cancer
Research Question
• To find the risk factors in patients with upper
extremity deep venous thrombosis;
• To find the incidence of acute complications
related to upper extremity deep venous
thrombosis;
Methodology
• Study populations was identified using ICD9 codes.
• Either admitting diagnosis or diagnosed during the hospital stay.
• Retrospective chart review.
• Data from last three years.
• At Sisters of charity hospital and Mercy hospital of Buffalo.
• Used EMR and paper charts.
Inclusion criteria :
• Adults age above 18.
• Patients with newly diagnosed upper extremity deep vein
thrombosis.
• Diagnosis during hospitalization or at admission.
• Confirmatory evidence of diagnosis.
Exclusion criteria :
• Patients without confirmatory evidence in the
imaging will be excluded.
• Patients who have chronic deep vein thrombosis
with duration greater than 60 days.
• Other thrombosis like in lower extremity.
Results
Total charts :
327
Thrombosis in
UE: 272
UEDVT:
187
Excluded: 55
Superficial vein
thrombosis:
85
Age Distribution for DVT patients only
3.7
<18.49
18.5-24.99
25-29.99
34.7
32.1
29.4
30-39.99
Mean Weight
80.8 Kgs
Mean BMI
28.39
BMI
N
%
<18.49
7
3.7
18.5-24.99
60
32.1
25-29.99
55
29.4
30-39.99
65
34.76
100
90
Veins
90
85
80
84
70
60
50
40
42
30
20
10
0
Axillary
Subclavian
Brachial
Internal Jugular
Presenting Signs/Symptoms
160
140
148
120
100
80
60
59
40
20
24
17
0
Swelling
Pain
Erythema
Other
DVT Prophylaxis
44(24%)
NO
Arrived
126(67%)
17( 9%)
YES
PICC
Frequency
82
%
43.9
Cumulative %
43.9
CVC/Dialysis/Mediport 34
18.2
62.0
Pacemaker/AICD
14
7.5
69.5
Unidentified
12
6.4
75.9
none
45
24.1
Total
187
100.0
100
Co-Morbidities
N
Percentage
HTN
121
61.7
Cancer
63
33.7
Dyslipidemia
61
32.6
COPD
58
31
DM
56
29.9
CHF
53
28.3
Sepsis
51
27.3
CAD
46
24.6
Hypothyroidism
38
20.3
CKD
37
19.8
CVA/TIA
20
10.7
H/o Hypercoagulability
18
9.6
Mechanical
7
3.7
COMPLICATIONS DURING THE
HOSPITALIZATION
7.5%
4.8%
1.1%
PE
SVC
Other
None
86.6%
N
%
PE
14
7.5
SVC
9
4.8
Other
2
1.1
None
162
86.6
Total
187
100
Comparing
Upper extremity
deep venous thrombosis with
superficial venous thrombosis
<40
41-50
51-60
61-70
>71
Total
Deep VT
12
24
31
37
83
187
Superficial
VT
9
10
8
15
43
85
Total
21
34
39
52
126
272
Symptoms
DVT(%)
SVT(%)
p Value
Relative risk
CI
Swelling
148(79)
69(81)
0.699
0.975
.85-1.1
Pain
59(31)
17(20)
0.04
1.57
1.1-2.5
Erythema
17(9)
8(9.4)
0.932
0.96
0.43-2.32
Lines frequency in Deep venous thrombosis and
Superficial venous thrombosis patients
PICC
CVC/Dialysis Pacemaker/ Unidentified
/Mediport
AICD
None
DVT
82
34
14
12
45
SVT
25
9
2
2
47
Total
107
43
16
14
92
COMORBIDITY
DVT(%)
SVT(%)
p-value
RR
CI
HTN
121(65)
51(60)
0.45
1.07
0.88-1.32
SMOKING
92(49)
38(44)
0.492
1.10
0.83-1.45
CANCER
63(33)
10(12)
<.0001
2.86
1.54-5.30
DYSLIPIDEMIA
61(33)
26(31)
0.73
1.06
0.729-1.56
COPD
58(31)
21(25)
0.28
1.25
0.81-1.92
DM
56(30)
26(31)
0.91
0.97
0.66-O.852
CHF
53(28)
18(21)
0.21
1.33
0.83-2.14
COMORBIDITY
DVT(%)
SVT(%)
p-value
RR
CI
SEPSIS
51(27)
19(22)
0.39
1.2
0.77-1.93
CAD
46(24)
16(19)
0.29
1.3
0.78-2.17
H/o DVT
39(20)
7(8)
0.017
2.53
1.18-5.42
HYPOTHYROIDIS
M
38(20)
8(9)
0.004
2.15
1.05-4.42
CKD
37(20)
5(6)
0.004
3.36
1.37-8.25
CVA/TIA
20(11)
8(9)
0.74
1.1.3
0.522-2.47
H/o
Hypercoagulable
18(10)
2(3)
.05
4.09
0.97-17.23
Frequency of Complications in hospitals
For Pulmonary embolism comparing DVT and SVT p Value is 0.211 rr: 2.12, CI: 0.62-7.18
Complications during hospitalization comparing Deep VT vs. Superficial VT
p Value: 0.013, rr: 3.78 CI: 1.17-12.2
Discussion
Demographics:
• Age
– 65% of patients are above the age of 65.
– Mean age is higher compared to RIETE study.
• Gender:
– No major difference.
• Race:
– More common in Whites.
– Results are similar to the study done at University at California.
• BMI:
– Increase in BMI increases risk for UEDVT.
– Average weight is higher than other studies.
Risk Factors:
• Smoking:
– Nearly 50%.
• HTN, COPD, Cancer, Dyslipidemia:
– In more than 1/3rd of patients.
• CHF, Sepsis, CAD:
– In more than 1/4th of the patients.
Investigation tool:
• US is the most commonly used diagnostic modality
– Sensitivity75-95%.
– Specificity 95-98%.
Symptoms:
• Swelling is the most common symptom.
Lines:
• PICC, CVC, PACEMAKER/AICD: 75%.
• 2/3rd of patients were on DVT prevention prophylaxis with anticoagulants.
Comparing UEDVT and Superficial vein:
• Pain is associated with UEDVT;
• Lines are important risk for UEDVT compared to SVT;
• History of previous DVT increases risk for future DVT compared to
SVT;
• Cancer, CKD and Hypothyroidism are associated with UEDVT than
SVT;
• Overall more complications from UEDVT during hospital stay;
• Study done by Liviu et al (publishes in Chest in 2008) it showed
statistically significant association of hypothyroidism and DVT. No
studies particularly on UEDVT.
• Daneschvar et al study has shown the association between the
UEDVT and CKD. They compared the 268 patients with CKD with
4,307 patients with preserved kidney function. 30% Patient with
CKD had UEDVT compared to 10 without ckd.
• A study at University of California by Jung-Ah lee on 373 UEDVT
patients cancer was diagnosed in 48% of patients. We had lesser
number of patients with cancer however hospitals we conducted
study does not have dedicated cancer floors.
Conclusions
• Clinical profile of patients with UEDVT and Superficial thrombosis were
variable.
• Suspect UEDVT compared to Superficial thrombosis
– Swelling
– Cancer
– CKD
– Hypothyroidism
– With Lines
• Patients with UEDVT overall experience more complications than
Superficial vein thrombosis during the hospital stay.
• First study to find differences in risk factors for Deep vein thrombosis vs
Superficial thrombosis in Upper extremity.
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Special thanks
Mentors: Dr. Qazi & Dr. Anain.
Guidance: Dr. Woodman & Dr. Tourbaf.
Acknowledgement
Statistician: Dr. Satchidanand.

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