Giuliana Guazzaloca

Unità Operativa di Angiologia e Malattie della Coagulazione

Policlino S.Orsola-Malpighi Bologna

TVP Arti superiori Epidemiologia

4-10% di tutte le TVP 4-16/100.000 individui anno Prevalenza stimata 2/1000 pz ricoverati

Vene del distretto brachiocefalico

v. Cefalica

v. Giugulare Esterna

A e V Ascellare

A e V Succlavia

V. Giugulare Interna

TVP arto superiore : patogenesi

NEJM 2011;Kucher

Trombosi venose del distretto brachiocefalico Primarie ‒ Intensa attività muscolare dell’arto superiore

‒ Sindrome dello stretto toracico superiore (congenita o acquisita)

‒ Trombo occludente

‒ Sintomatiche: dolore e edema, affaticamento dell’arto, presenza di circoli collaterali

Maschi 2:1 Età 2-3 decade Anomalie ossee, muscolari, inserzione tendini Bilaterale nel 50% dei casi

Trombosi venose del distretto brachiocefalico

Secondarie

‒ 80% CVC correlate

‒ Trombosi parzialmente occludente (murale, di punta)

‒ Asintomatiche nei 2/3 dei casi (sintomi dipendono da localizzazione della trombosi)

Complicanze Embolia polmonare 15% Perdita accesso venoso Sepsi

Catheter-related Catheter design (PICC > Hickman > implanted port) Material (polyethylene or polyvinylchloride > silicone or polyurethane) Presence of valves (nonvalved > valved) Catheter tip position (proximal to SVC and RA junction) Number of lumens (triple > double > single) Larger catheter caliber or diameter Catheter occlusion

Insertion-related Vein entry (femoral > subclavian > jugular) Insertion technique (percutaneous > cut-down > ultrasound guided) Left-sided insertion (> right-sided) Previous catheterization, traumatic insertions or multiple attempts Patient-related History of venous thromboembolism Heritable thrombophilia Infection Tumour type and status

Potential risk factors for catheter-related thrombosis

A. Y. LEE, P. W. KAMPHUISEN et al. J Thromb Haemost 2012; 10: 1491–9

Ultrasonografia I scelta: diagnosi TVP (sensibilità 97% e specificità 96%)

localizzazione, estensione, diagnosi differenziale Limiti: inadeguata finestra acustica, impossibilità di

visualizzare i vasi intratoracici, Angio TC/RM II livello: studio vasi venosi intratoracici, studio dei vasi

in posizione statica e dinamica, studio morfologico degli organi e tessuti circostanti, diagnosi di compressione, infiltrazione. AngioTC : diagnosi di embolia polmonare

Flebografia III livello: finalizzata a terapia interventiva (trombolisi,

trombectomia, dilatazione e posizionamento di stent su stenosi residue)

TVP arto superiore: metodiche diagnostiche

Diagnosi di TVP degli arti superiori

Sartori et al. JAMA Internal Medicine July 2015 Volume 175, Number 7

Armour Study Kleinjan et al Ann Intern Med. 2014; 160: 451-7

Ann Intern Med. 2014;160:451-457.

249 patients with a normal diagnostic work-up, followed for 3 months. One pt developed UEDVT; overall failure rate:0.4% (95% CI, 0.0%-2.2%).

ECD criteri diagnostici di TVP

Visualizzazione diretta del trombo Incompressibilità della vena Assenza di flusso Flusso continuo anche con manovre di attivazione nel

segmento a valle dell’ostruzione trombotica

CUS Arti superiori

TVP arto superiore prognosi UEDVT

LEDVT

Study VTE % PE % Mortality% VTE %

PE% Mortality%

RIETE 3 mo 2.3 1.8 11 1.7 1.2 7.7

Worcester 1 mo 8.7 1.5 4.4 4.6 1.2 5.8

6 mo 15.9 1.5 14.5 9.4 2.2 12.1

12 mo 14.5 1.5 20.3 11.4 2.9 14.7

PTS of the arm (27–50%)

CRT profilassi

Kirkpatrick et al AJM 2007;120:901-910

CRT profilassi

Kirkpatrick et al AJM 2007;120:901-910

Prophylaxis of thrombosis associated with central venous catheters in patients with cancer

British Committee for Standards in Haematology

Recommendation:

Routine use of anticoagulants at prophylactic or therapeutic dose to prevent catheter-related thrombosis in cancer patients is not recommended [Grade 1A]..

Guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12: 796–800

Recommendations

Use of anticoagulation for routine prophylaxis of CRT is not recommended [Grade 1A]..

Catheters should be inserted on the right side, in the jugular vein, and the distal extremity of the central catheter should be located at the junction of the superior vena cava and the right atrium [Grade 1A]

We recommend against the routine administration of heparin flushes to prevent catheter-associated deep vein thrombosis.

Trattamento della TVP arto superiore

Strength 1 B 2 B 2 C 2C 2C 2C

ACCP; 2012

Algoritmo terapeutico da Circulation 2012;126:768-773

Guidance statements for the acute treatment of a catheter-associated upper extremity deep vein thrombosis in

cancer patients Low-molecular-weight heparin without removal of the catheter if the central venous

catheter is functional and required for ongoing therapy.

We recommend removal of a non-functional, infected or incorrectly positioned catheter and suggest anticoagulation with low-molecular-weight heparin

We suggest a short duration of anticoagulation (3–5 days), if clinically practical, prior to removal of a central venous catheter.

We suggest removal of a central venous catheter without anticoagulation if therapeutic anticoagulation cannot be safely adminisered due to the active risk of hemorrhage.

We suggest anticoagulation over no anticoagulation for an incidental catheter-associated DVT. Alternative strategies such as serial ultrasound and/or catheter removal can be considered

We recommend anticoagulation over thrombolysis for the acute management of catheter-associated thrombosis. Consideration of clot-directed thrombolysis should be reserved for cases of massive clot burden and/or refractory thrombosis

In cases of thrombocytopenia without bleeding, the decision to anticoagulate or withhold anticoagulation should be made on an individual basis.

J Thromb Haemost 2014; 12: 796–800.

Trombosi della punta del catetere

Instillation of 2-mg t-PA is recommended to restore patency and preserve catheter function

If there is radiologically confirmed thrombosis that does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated, catheter removal is recommended

(Central Venous Catheter Care for the Patient With Cancer American Society of Clinical Oncology Clinical Practice Guideline)

Instillazione nel CVC di massimo 2 dosi di rt-PA alla concentrazione di 1 mg/ml (1 ml nei < 30 kg, 2 ml se peso superiore > 30 Kg) lasciati in sede per 20 minuti a 4 ore

ripristino pervietà del lume 80-98% casi

(Choi et al, 2001;Chesler &Feusner, 2002;Baskin et al, 2009;Soyluet al, 2010;Doellman, 2011).

R Moore, Y Wei Lum J Vascular Medicine 2015, Vol. 20(2) 182–189

Outlet Thoracic syndrome terapia

84 pz con effort thrombosis Terapia anticoagulante per 2 settimane indipendentemente

da trombolisi Resezione della I costa per via transascellare Dopo 2 settimane flebografia di controllo per valutare

pervietà Se persistenza della stenosi, dilatazione o prolungamento

dell’anticoagulazione Monitoraggio clinico per escludere retrombosi 94% di pervietà dell’asse venoso dopo 1 anno

(M S Orlando, K C Likes et al. J Am Coll Surg 2015;220:934-939)

TVP arto superiore Filtri VCS Utilizzati raramente per la difficoltà di posizionamento dovute alle dimensioni

del vaso (lungh.7 cm)

Da valutare se: controindicazioni alla terapia anticoagulante, o fallimento terapeutico

Complicanze: perforazione del vaso, dislocazione, tamponamento cardiaco, occlusione

Ascher et al : Case control study 72 patients followed for 22 months Greenfield filter placed due controindication to anticoagulation or exetension of thrombus despite anticoagulation - 1.3 % complication rate , no new PE , 47% mortality due to underlying disease

Spence et al. Case series of 41 patients median follow up was 15 months SVC filter placed due to controindication to anticogulant or failure of anticoagulation.No new PE documented, no complications, mortality rate 51% at 1 year