Compared to lower extremity DVT, UEDVT is an
uncommon disease representing about 10% of all
DVTs.[
1] It can be associated with mechanical or
anatomical factors (e.g. insertion of central venous catheters or narrowing of veins by cervical rib) and
hypercoagulable states (e.g. anti-thrombin deficiency,
malignancy and anti-phospholipid syndromes).[
2] In
addition, UEDVT can be associated with pulmonary
embolism (PE) with reported incidence rates of about
up to one third of all patients.[
3] Since our patient’s
vital signs were normal and there was little clinical
evidence of PE, the possibility of PE was considered
to be low. Moreover, echocardiographic examination
showed normal right ventricular function and normal
pulmonary arterial pressure.
It has been assumed that thrombolytic therapy
for UEDVT may reduce the risk of long-term
complications, especially the troubling PTS,
characterized by chronic arm and hand aching and
swelling due to early restoration of venous patency,
thereby minimizing damage to vessel valves and
endothelium. Recent retrospective[6] and prospective[7,8]
cohort studies of conventional anticoagulant therapy
for unselected UEDVT reported to be 27% to 44%
mild PTS and almost no severe PTS. Although some
cohort studies have evaluated short-term efficacy,
adverse events, and reocclusion rates, we found no
reports assessing the development of PTS after initial
UACDT with subsequent conventional anticoagulant
therapy for UEDVT.
Due to its rarity and possible variations in
anatomical obstruction associated with UEDVT, there
is no unique and unequivocal management strategy.
Most patients are unresponsive to anticoagulation
alone, which appears to be effective only in the mildest
cases. However, life-long anticoagulation following
definitive endovascular therapy may be important to
reduce the incidence of reocclusion and may play a role
in maintaining collateral circulation.[9]
Endovascular stents have become the treatment
of choice for acute symptom relief of such patients.
When stent placement is difficult or dangerous due to the presence of a large amount of thrombus,
thrombectomy, or thrombolysis should be attempted
prior to stent deployment. On the other hand, stent
placement for treatment of UEDVT is not devoid of
complications. Infections, pulmonary embolus, stent
migration, hematoma at the insertion site, bleeding,
and rarely, perforation or rupture of the venous
structures resulting in death, have been previously
reported.[10]
As thrombus is deemed to be the cause of the upper
extremity deep venous obstruction, removing it using
UACDT with a low dose of thrombolytic agent may
result in reduced risk of hematoma, gastrointestinal
bleeding, and shorter length of hospital stay with all
the relevant cost and comorbidities. To overcome the
limitations posed by long-term treatment and highdrug
doses in catheter directed thrombolysis, UACDT
enhances drug permeation through thrombus by
disaggregating the fibrin matrix, exposing additional
plasminogen receptor sites to the thrombolytic
agent.[4,5] The US energy affects thrombus in the
entire venous segment, increasing the probability of
complete thrombus clearance. The significant benefit
of complete thrombolysis, compared to partial lysis,
has been demonstrated in previous studies of standard
thrombolysis.[11] Therefore, the ability of this technique
to penetrate and resolve the entire thrombus may
potentially lead to increased long-term patency rates
and better long-term outcomes.
Recent literature data have shown a potential benefit
of adjuvant angioplasty and stent implantation of the
residual venous stenosis in patients with UEDVT.[12]
Also, Alteplase has a high-degree of safety with few
complications when delivered by a catheter rather than
the traditional systemic infusion.
In conclusion, UACDT may represent a potential
therapeutic alternative in patients with severe UEDVT,
particularly in those in whom medical management fails or conventional thrombolytic therapy and surgical
thrombectomy are contraindicated or considered
extremely risky.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.