*From Pulmonary and Critical Care, Ohio State University Medical Center, Columbus, OH.
Correspondence to: Philip Diaz, MBBCh, 201 DHLRI, 473 W 12th Ave, Columbus, OH 43210; e-mail: firstname.lastname@example.org
A 47-year-old man with diabetes mellitus and hypertension was admitted with acute left upper extremity pain, swelling, and redness. He complained of dyspnea, left pleuritic chest pain, and a productive yellow cough, occasionally being blood streaked. Ten days ago, he was admitted for diabetic ketoacidosis. During that time, he had a peripheral IV line in his left forearm.
Initial examination revealed an obese man; temperature, 39°C; heart rate, 110 beats/min; BP, 113/74 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 87% on room air. Auscultation revealed bilateral scattered crackles and normal heart sounds. His left forearm was swollen, erythematous, and tender.
Test results included hemoglobin, 10.7 g/dL; WBC count, 5.5 × 103/μL; and platelets, 91 × 103/μL. The serum sodium was 127 mmol/L; BUN, 38 mg/dL; creatinine, 2.8 mg/dL; and bicarbonate, 16 mmol/L. Room air arterial blood pH was 7.415; Paco2, 29 mm Hg; and Pao2, 52 mm Hg. The international normalized ratio was 1.4, and prothrombin time was 28 s. Laboratory evaluation for an underlying thrombophilic state was negative. The chest radiograph is shown below (Fig 1
). A left upper extremity venous duplex study indicated a superficial thrombophlebitis as well as partially occlusive chronic upper extremity deep vein thrombosis (UEDVT). Transthoracic echocardiography showed no evidence of endocarditis.
Antimicrobial therapy was initiated that included IV vancomycin. Blood and BAL cultures grew methicillin-resistant Staphylococcus aureus. In the interim, IV heparin was commenced due to the left UEDVT but subsequently discontinued due to an upper GI bleed. Once the creatinine normalized, the patient underwent a contrast-enhanced chest CT (Fig 2
). This revealed bilateral pulmonary emboli (PE) and multiple cavitary nodular consolidations. During the same period, extensive bilateral lower extremity deep vein thromboses (DVT) developed. When the bacteremia cleared, an inferior vena cava (IVC) filter was placed.
The final diagnosis is methicillin-resistant S aureus bacteremia with septic PE, bronchopneumonia, acute renal failure, and left UEDVT.
Therapy for UEDVT has remained controversial. We describe a case of septic PE due to superficial thrombophlebitis with underlying chronic, nonocclusive DVT of the left upper extremity. Since the reported incidence of PE has been in the range of 4 to 28% in patients with UEDVT, making it comparable to that of lower extremity DVT, some authors recommend systemic anticoagulation. Fatal embolization occurs in 1 to 2% of patients with UEDVT (8% in one series), highlighting the danger associated with this condition. Other complications of UEDVT include postphlebitic syndrome and loss of future venous access. Therefore, it is recommended to use systemic anticoagulation for UEDVT as these complications could be averted.
The early experience with superior vena cava (SVC) filters stemmed from a 1985 animal experimentation by Langham et al. The thrombus was intentionally embolized after SVC filters were implanted into 11 dogs. After 3 months, at autopsy, all filters were patent with no evidence of PE or major complications.
In patients with UEDVT, indications for SVC filters include contraindications to anticoagulation, proximal thrombus extension, or PE despite adequate anticoagulation and free-floating clot that is at risk for eminent embolization. Contraindications include extensive SVC thrombus, SVC diameter > 28 to 30 mm, significant coagulopathy, and the presence of a venous pacemaker.
Two major case series and isolated case reports summarize the clinical experience gained with using SVC filters. The first of the studies, from the Cleveland Clinic in 1999, included 41 patients over a 9-year period. No complications or clinical evidence of PE/SVC syndrome were encountered. However, it must be noted that the median follow-up was only 15 weeks. A series of 72 patients by Ascher et al published in 2000 remains the largest to date; 47% of patients died in hospital of causes unrelated to the SVC filter or recurrent thromboembolism. The appropriateness of SVC filter placement in critically ill patients remains controversial. Mean follow-up of the survivors was 22 months. None of these patients were seen with any clinical evidence of PE or SVC thrombosis, and indeed had no major complications related to the device. The lack of long-term data on permanent SVC filters suggests a role for a nonpermanent filter if the clinical circumstances allow. The first report of a temporary SVC filter that was successfully retrieved was published by Watanabe in 2001. Since that time, there have been at least three other reported cases.
Utilization of SVC filters has the potential for serious complications. Due to anatomic constraints, it is technically more challenging compared to IVC placement. Possible complications include cardiac tamponade, filter fracture, migration, and thrombosis. Reported events from the series of Ascher et al include a device that was discharged into the innominate vein and a filter that was dislodged by a J guidewire during central line insertion. The latter filter remained in the innominate vein without further sequelae. Occlusion of the SVC after SVC filter insertion has been described in two patients with adenocarcinoma of the lung. A recent report indicated that SVC perforation and cardiac tamponade occurred shortly after the deployment of a SVC filter in a trauma patient. This is the only case of its kind reported in the literature.
Thrombus propagation and the postphlebitic complications of DVT are unaffected by filter placement; therefore, anticoagulation should be instituted or reinstituted whenever possible. One major concern regarding SVC filter use is the impact on central venous access. If a central venous catheter is already in situ prior to SVC filter placement, it is recommended that it be removed or at a minimum be retracted to allow for safe filter deployment. In both major case series, multiple central venous devices were used. These included regular central venous catheters, Swan-Ganz catheters, and venous pacemakers. Such procedures should be performed with fluoroscopic guidance. Notably, a number of cases have been reported describing successful simultaneous insertion of SVC and IVC filters due to concomitant UEDVT and lower extremity DVT.
Whether thromboembolism related to UEDVT can justify aggressive therapy remains controversial. However, the underlying etiology of the thrombosis may play a role in the embolic potential of UEDVT. It has been postulated that thrombosis related to central venous catheterization is more likely to embolize than other causes of thrombosis of the upper extremity. In our patient, there was no history of central venous catheterization, so one could make the assumption that his inherent risk of embolization from the UEDVT is substantially lower. Significantly, the UEDVT was nonocclusive. The natural history of these nonocclusive thrombi is unknown. Because of the lack of data, it has been recommended to treat these patients with anticoagulation and reserve SVC filter placement when clearly indicated.
Because our patient’s thrombus was nonocclusive and not central venous catheter related, we deemed the risk for significant embolization to be fairly low. As such, we decided not to insert a SVC filter. Our patient improved rapidly and was subsequently discharged home.
A significant proportion of UEDVTs embolize; therefore, systemic anticoagulation is required.
Central venous catheter-induced UEDVT seem to have more significant embolic potential than those due to other causes.
Indications for SVC filter insertion include proven UEDVT with contraindications to systemic anticoagulation, and either PE or thrombus propagation despite systemic anticoagulation.
After SVC filter insertion, anticoagulation should be instituted if clinically permissible. This would help retard thrombus propagation and postphlebitic complications.
It is fairly safe to use central venous catheters, Swan-Ganz catheters, and venous pacemakers with in situ SVC filters. Fluoroscopy and straight guide wires should be used during insertion of these devices.
The authors have no conflicts of interest to disclose.
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