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Upper extremity deep venous thrombosis. Underdiagnosed and potentially lethal.

M D Black, G J French, P Rasuli and A C Bouchard Chest 1993;103;1887-1890 DOI 10.1378/chest.103.6.1887

The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/103/6/1887

CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 1993 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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DIsCussIoN Pulmonary
aspiration of

actinomycosis
oropharyngeal

usually
material

occurs
in the

as a result
setting

of the

of poor
it is

Upper Extremity Thrombosis*


Underdiagnosed
Michael Pasteur D. Black, M.D.; and Piasuli, M.D.; Gordj

Deep Venous
and Potentially
French, M.D.; M.D.

dental
invasive,

hygiene often

or oral mimicking

trauma. When pathogenic, a malignancy in presentation


Endobronchial disease due

Lethal

and
to this

macroscopic

appearance.

Adrien

C. Bouchard,

pathogen rarely is reported. Ariel et al recently described five patients presenting with endobronchial actinomycosis presenting in a subacute fashion, similar to the presentation in our patient. Endobronchial infection is thought to be due to implantation of infected aspirated material, lymphohematogenous spread to the peribronchial region, or endobronchial implantation of infected secretions from draining cavitary lesions. Although the diagnosis of actinomycosis was presumptive since the cultures of all specimens were negative, this was not an unexpected finding in light of antibiotic therapy administered prior to bronchoscopy. In addition, the finding
of a sputum culture positive for H influenzae is common Coexisting in

The significance ofupper extremity deep venous (DVT) has been minimized in comparison to thrombosis, likely due to the erroneous belief quent pulmonary thromboembolism is rare. The of pulmonary thromboembolism originating in
extremity
catheters

thrombosis iiofemoral that subsepossibility the upper


with

veins

must

now

be

seriously

considered

medical instrumentation being performed more commonly in accessing the central venous system. It has been incorrectly assumed that the risk of pulmonary embolism was low due to the abundant collateral flow, and thus lack of stasis around an upper extremity even with venous occlusion. However, several studies, including a
recent prospective trial,
concluded that

and

the setting organisms


may

of Actinomyces pulmonary infection. such as fusobacteria, streptococci and


as well.

pulmonary

embo-

Eikenella

lism

is not

be cultured

Even among immunocompromised hosts, such as patients on chronic steroid therapy or cancer chemotherapy, actinomycosis has not been shown to have an increased prevalence of infection. Actinomyces is a rare pathogen in the HIVinfected population. This is most likely due to the partial susceptibility of the organism to antibiotics commonly used to treat persons with AIDS such as trimethoprim-sulfamethoxazole, isoniazid, rifampin and the cephalosporins. Why this particular patient developed actinomycosis infection with endobronchial disease is unclear. Although his oral hygiene appeared to be maintained, there may have been
unsuspected aspiration of oropharyngeal secretions which

Significantly, upper extremity DVT

a rare complication when comparing


DVT,

in upper extremity DVT. all sources of secondary


upper extremity

catheter-related

risk of subsequent pulmonary thromboembolism. We present an ifiustrative case documenting extensive pulmonary embolization that occurred following insertion of a central venous catheter and subsequent thrombosis of the right subclavian and innominate veins. With absolute contraindications to thrombolytic and anticoagulation therapy, prevention of further embolization
was
cava achieved filter. by percutaneous insertion of a superior vena

is at greatest

(Chest

1993;

103:1887-90)

subsequently led to endobronchial disease. The possibility that the endobronchial tissues may have been secondarily involved from a more distal infection, as seen in tuberculosis,
also must be entertained. The subacute initial lack ofresponse to orally administered presentation, antibiotics the and is

DVT

deep

venous

thrombosis;

SVC

superior

vena

cava

C
sions

omplications
categorized

of subclavian
into three main

vein

thrombosis
subgroups:

may
pulmonary

be

the development
spectrum consistent lesions with are
AIDS

of a new infiltrate
administered infection. this

while

receiving

a broadregimen

embolism, the postthrombotic syndrome, and venous gangrene. More common in the medical literature are discusrelated rare
of in discuss

intravenously with noted

antibiotic

to

the

postthrombotic of venous
vein to iiofemoral thrombosis

syndrome gangrene.
has thrombosis, been this

and Since

the the
mini-

extremely

occurrence
subclavian

Actinomycosis

also must
at the

be considered
of bronchoscopy

when infection.

obstructing
in a patient

significance mized

time

comparison

article

and a suspected

pulmonary

will

(DVT)
pulmonary

ofthe

the significance upper extremity


embolism
.

of deep venous thrombosis and its relevance to subsequent


REPORT admitted worsening claudication included a left against to the hospital right lower for further limb claudisix for advice. operations graft, a

REFERENCES

A, Talavera W, Rorat E, Salsitz E, Widrow C. Pulmonary actinomycosis in a patient with HIV infection. Mt Sinai J Med 1982; 49:136-39 2 Miracco C, Marmno M, Lio R, Cornetti M, Luzi P. Primary
endobronchial 3 Ariel E. noma. 4 Wasser the A, Breuer Endobronchial Chest LS, acquired BA, Shaw actinomycosis. R, Kamal N, actinomycosis Eur Respir simulating W. Endobronchial syndrome. BA, Greenberg Neck Surg Chest MS.

1 Klapholz

CASE

A 67-year-old
investigations

white

man

was

of progressively

1988;

1:670-71 P, Rosenmann carciin

Ben-Dov

I, Mogle

cation. The years. The bronchogenic


hospital

patient
patients

had bilateral
history He continued

for approximately thoracotomy medical The

adenocarcinoma

four

years

previous

to his current reconstructions,


bypass

bronchogenic tuberculosis 1988;

admission.

to smoke

1991; 99:493-95
GW, Talavera immunodeficiency Hone

The
each

patient had one unsuccessful


were

multiple attempted vascular ultimately due to thrombosis.


composite femoropopliteal

94:1240LT

that

failed

an in situ

44
5 Yeager

Actinomycosis lated complex. 95

J, Weisman in the acquired


Otolaryngol

Bilaniuk

immunodeficiency Head

syndrome
1986; 112:1293-

re-

Arch

*From the Departments of Surgery (Drs. Black and Bouchard) and Radiology (Drs. French and Basuli), the Ottawa General Hospital and the University ofOttawa, Ontario, Canada.
Reprint requests: Dr. 10,53 Carling Avenue, Black, Ottawa, University Ontario, of Ottawa Heart Institute, Canada K1Y 4E9

CHEST

I 103 I 6 I JUNE,

1993

1887

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FIGURE

1. Superior
ofthe

the

confluence

There

is reflux

defect bulging proximal SVC

veins, contrast being injected. ofcontrast into the left innominate vein, not a filling from the right innominate vein (arrow) into the
consistent with thrombus.

vena cavogram. two innominate

The

catheter

is positioned

at

FIGURE 2. Posteroanterior tory filter position just veins (arrow).

chest radiograph demonstrating inferior to the confluence of the

satisfacinnominate

placement

of the Findings

filter.

Pathologic
was extensive

A full autopsy

demonstrated bilateral following: (1)

that recurrent

the

immediate Further adenocarcinoma

cause significant

of death findings of the left

a revision of the previous graft, and finally a right axillofemoral and femoropopliteal graft. The patient eventually underwent a right above-knee amputation. The patients postoperative course was
complicated by the development of gastrointestinal bleeding, con-

pneumonitis.

included

the

gestive
care failure
gram

heart
unit (ICU) prompted were

failure,

and

pulmonary
continued and showed

sepsis.
and scan a possible bilateral leg has of the was The and obtained femoral

During
progressive to rule

his intensive
respiratory out pulmonary angiodefects showed above-knee and was in the correction iliac then right for there a left vena femoral cavogram no

lung with involvement; malignancy

left

pleural metastases and mediastinal lymph node (2) a thrombotic state secondary to the pulmonary with recent massive pulmonary thromboemboli, mainly
and thrombosis resulting marked left leg or the
DISCUSSION

admission,

a ventilation-perfusion A venogram

in the right lung, SVC (Fig 3) with

of the filter and occlusion edema of the right arm; right lower extremity

of the and (3)

thromboembolism. requested. The consistent evidence amputation, veins advanced was The the lature obtained superior presence suggestive as well approach; ventilation-perfusion with of

pulmonary mismatch a right right femoral via catheter

no DVT found

in the

stump.

scan emboli. the Because vena from right

pulmonary

A left patient

venogram

Recognition
The possibility of pulmonary thromboembolism originat-

DVT

a transcatheter as inferior free the all were through (Fig

venogram cava clot. atrium revealed

a superior thrombus after

1). This

a large

innominate magnification.

vein,
vena

the most
cava (SVC)

likely

source

of the pulmonary
24 mm emboli.

emboli. confirming vascucontra-

measured

Pulmonary
of bilateral

angiography
pulmonary

was performed,
Furthermore, carcinoma. bleeding

was a suggestion
Because

of extrinsic
of a recurrent

compression
bronchogenic

of the pulmonary

of a history

of recent

gastrointestinal

indicating
peared emboli

anticoagulant
to be the best from access superior vein orientation when patients ICU used condition to the surgical deteriorated originating introducer vein SVC

therapy,
option the and (Vena thrombus Tech) the to the introduction (apex in the inferior ward and

placement
in the inserted was set caudad), vena and eventually was course

of an SVC
the right lungs through of the to place from the innominate in the

filter

apvein.

for protecting was filter expected

further existing proximal vein filter filters the

A filter

left femoral
third (Fig in the orientation The from his the of the correct

released used cava. he was died

azygos to the

2). A jugular

ie, opposite later

improved, he

transferred

for convalescence.

Unfortunately, of respiratory
FIGURE

condition

3. Postmortem
(arrow) and occlusion

specimen
ofthe

demonstrating
SVC.

thrombosis

of the

failure 1888

secondary

to severe

pulmonary

sepsis

weeks

following

filter

Upper Extremfty

Deep

Venous Thrombosis

(B!ack et a!)

Downloaded from chestjournal.chestpubs.org by guest on November 16, 2009 1993 American College of Chest Physicians

ing

from

the

upper

extremity

veins

must

now

be

seriously

venous
nary

return, Insertion

megacava,

but also the possibility


origination in the upper

of pulmoextremity

considered with catheters and pacemaker hardware cornmonly being utilized in accessing the central venous system. It is now well established that pulmonary embolism frequently presents in an asymptomatic fashion.s.4 It is therefore not surprising that 30 percent ofthose with angiographically proven pulmonary ernboli have a normal lower extremity venogram.5 Etissible explanations for the latter finding could include either (1) embolization of all thrombi to the pulmonary circulation or (2) emboli derived from a source other than the deep veins of the legs, le, the deep veins of the upper extremity.3 Source Our case provides direct evidence that DVT ofthe upper extremity may be the source of lethal pulmonary thromboembolism. Thrombosis ofthe subclavian veins may be either primary or secondary. The condition is rare, occurring in less than 2 percent of all cases of venous occlusion prior to 1967.#{176} Undoubtedly, the incidence has risen with more frequent use of these veins for treatment of a variety of medical problems. Primary thrombosis generally occurs following exertion, as exemplified by the high occurrence of cases in the dominant upper extremity. Approximately 25 percent of cases of primary thrombosis arise spontaneously without a recognized predisposing event.#{176} Secondary thrombosis, which occurs more often, can occur due to local sources of inflammation and/or compression, le, scierosing intravenous solutions, foreign bodies such as catheters, and anatomic variations at the thoracic outlet. Clots have been found to form at the site of venipuncture and extend along the venous catheter. Swinton et al suggested that pulmonary embolism was more frequent and severe in patients with secondary thrombosis ofthe upper extremities. Hypercoaguability states, a manifestation of serious
disorders,

thromboembolism

veins.

circumstance It is hoped
in

of an inferior vena would be disastrous!


that upper be extremity
contemplated

caval

filter

in the latter
and perhaps

venography,

the

near

future
will

duplex occurs

scanning- in the presence


vena been caval

and
whenever

light

reflection
pulmonary

rheography,a thromboembolism

ofupper
placement

extremity
of venous

venous filters
further

access. in humans
protection

Superior has rarely


of

performed
pulmonary

recurrent

but may provide embolism when

other

modes

of therapy Information

are contraindicated. With Regard to

Technkal
Insertion

SVC Filter

Prior to the insertion of the filter, the distance between the left groin and the SVC should be measured, using a guide wire clamping technique. In our case, this indicated that the introducer was of adequate length. It should be noted that in our patient, who was of average height, the total length of the introducer had to be inserted in order to

deliver suggest

longer
devices

for patients greater than introducers be used. A potential


is that they

the that

ifiter

to

the

desired

location.

We

therefore

170 cm

therapy astinal
massive

because bleeding
pulmonary

problem may preclude the use of thrombolytic of fear of excessive retroperitoneal medi-

in height, with these

or from

the

thromboembolism

development oftemporary the latter fears.

should further The recent and vena caval filters may negate
occur.

insertion

site

CONCLUSIONS

preexisting

disease, such as neoplastic known to be associated with secondary markedly reduced survival. Treatment Unlike
treatment

systemic

are

thrombosis

well and a

the

rarer

sequelae
have yet

of upper
been advocated

extremity
for the

DV1
preven-

no

protocols

tion of recurrent pulmonary thromboembolism. Early yenous thrombectomy in the acute situation has been advocated in an attempt to prevent residual disability despite the initial effectiveness of anticoagulants.b0.h1l.19 4jtjc.#{231}gij lant therapy continues to be recommended solely or cornbined with surgery on the theoretical grounds of preserving venous collateral flow,#{176} thus possibly avoiding long-term disability. Fibrinolysis and anticoagulation therapies that seem most promising are likely to continue to serve as the primary noninvasive modalities prior to surgical correction ofany existing abnormalities. Blinded by Virchows identification that the lower limbs were the major anatomic source of pulmonary thromboembolism, technical advances and medical therapies for the prevention of further pulmonary thromboembolism have long centered around the inferior vena cava as the major avenue of subsequent thromboembolism. When contemplating the use of an inferior vena caval filter, the surgeon/ invasive radiologist must be aware ofnot only the anomalous

A recent prospective trial concluded that pulmonary embolism is not a rare complication in upper extremity DVT, and catheter-related VFseems to be at the greatest risk.2 Upper extremity DVT must now be taken seriously as a harbinger of possible pulmonary thromboembolism. As illustrated in our case, a combination of risk factors, ie, hypercoagulability secondary to recurrent pulmonary carcinoma, and the cannulation of the central veins made embolization from an upper extremity DVT possible. With the systemic and pulmonary venous systems being accessed
increasingly for a multitude of invasive diagnostic and

therapeutic
possibly

procedures,
newer less

upper
invasive

extremity
modalities

venography
should be

and
contem-

plated whenever pulmonary thromboembolism occurs in the presence ofupper extremity venous access. The insertion of an SVC ifiter may provide further protection against recurrent nulmonarv embolism when other modes of theranv
are contrarndicated.
REFERENCES

1 Hill SL, Berry RE. Subclavian challenge. Surgery 1990; 108:1-9


2 Monreal

vein

thrombosis:

a continuing

M, Lafoz E, Ruiz J, Valls R, Alastrue A. Upperextremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest 1991; 99:280-83 3 Harley DP, White BA, Nelson RJ, Mehringer CM. Pulmonary embolism secondary to venous thrombosis of the arm. Am J Surg 4 Monreal 1984; M, 147:221-24 Rey-Joly C, Ruiz

J,

Salvador

R, Lafoz

E, Viver

E.

CHEST

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1993

1889

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Asymptomatic thrombosis: condition? 5 Hull RD.

pulmonary is it useful

embolism to Surg take


1989;

in patients a lung
30:194-07

with

deep

vein

385-86 28 Hoffman MJ, by MR. superior Surg EW, 1985; Greenfield superior Etheridge vena 2:794-98 GP Harrington in the superior vena Schoettle caval U. vena JC, Central cava Crete venous Greenfield SI, septic filter thrombosis and U. venous Experi-

scan

to rule

out

this PA,
and

J Cardiovasc
Hirsh

managed
PE, Ockelford
lung scanning, 29 Langham mental Vase 30 Owen

J,

Carter

CJ, Jay RM, Dodd


ventilation

thrombectomy:

a case report.

J Vase Surg

1986; 4:606-11
Greenfield

et al. Pulmonary
venography

angiography,

for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med 1983; 98:891-99 6 Barker NW, Nygaard KK, Walters W, Priestley JT. A statistical study of postoperative venous thrombosis and pulmonary em-

placement

of the Greenfield OB. Placement cava. Ann Thorac

filter.

bolism:

IV

location Clin PW

of thrombosis-relation Proc III. HJG,

of thrombosis ofaxillary EA. and Natural

and

Greenfield filter 1992; 53:896-97

of a Surg

embolism. Mayo 7 Coon WE, Willis


veins. 8 fllney major 9 Campbell Axillary, gery 10 Hughs
Schrotters

1941;

16:33-37
subclavian history Arch Bernstein obstruction. of Surg EF. Sur-

Thrombosis Edwards of the upper

Arch NL, venous

Surg

1967; thrombosis

94:657-65 extremity. CJ, vein

Grifliths

1970; 101:792-96 CB, subclavian, 82:816-26 ESR.

Chandler
and

JG,

Tegtmeyer

brachiocephalic

Diagnosis of Pneumocystis Infection in HIV-Seropositive


Patients
p carinii
Thoina,s
Kenneth H. G. Taylor,

carinii
of
M.D.; M.D., FC.C.P

1977;

11 Swinton
axillary 12 Kakker

in the upper extremity (Pagetsyndrome). mt Abstr Surg 1949; 88:89-127 NW Jr, Edgett JW Jr. Hall RJ. Primary subclavianthrombosis. Howe Circulation AN, 1968; 38:737-45 JTC, Clarke MB. CI, Nicolaides Benney

Venous

obstruction

by Identification in Pleural Fluld*


Schaumberg, M.D.; M.D.; Lynn M. Schnapp,

vein VV

andJeffrey

A. Golden,

13

14

15

16

Deep vein thrombosis of the leg: is there a high risk group? Am J Surg 1970; 120:527-30 Pineo GF, Brain MC, Gallus AS, Hirsh J, Hatton MWC, Regoeczi E. Tumors, mucus production and hypercoagnlability. Ann NY Acad Sci 1974; 230:262-66 Carson JL, Kelley MA, DuffA, WegJG, Fulkerson WJ, Palevsky HI, et al. The clinical course ofpulmonary embolism. N EngI J Med 1992; 326:1240-45 Drapanas T, Curran WL. Thrombectomy in the treatment of effort thrombosis ofthe axillary and subclavian veins. J Trauma 1966; 6:107-19 Mahorner H, Castleberry JW, Coleman WO. Attempts to restore function in major veins which are the site ofmassive thrombosis. Ann Surg 1957; 146:510-22 JT, DeWeese JA. Effort thrombosis 11:923-30 VF, DaRocha E. Thromboof the axillary and

carinli pneumonia (PCP) is the most common complication ofAIDS and is typically diagnosed by the identification of P carinli organisms in sputum, bronchoalveolar lavage fluid, or tissue obtained with transbronchial biopsy. We describe two H1V-seropositive patients with pleural effusions in whom the diagnosis of P carinli infection was made by examination ofpleural fluid. Pleural effusions associated with PCP are very unusual but can provide a source ofthagnostic material particularly in those my patients who have development of a spontaneous pneumothorax and require chest tube insertion. (Chest 1993; 103:1890-91)
Pneumocystis

pulmonary

17 Adams

subclavian
18 Ochsner

veins.

J Trauma
M,

1971; DeCamp

AFBacid-fast
man

bacteria;

A, DeBakey

embolism: analysis ofcases at Charity Hospital in New Orleans over a 12-year period. Ann Surg 1951; 134:405-19 19 Adams yI McEvoy RK, DeWeese JA. Primary deep venous thrombosis ofupper extremity. Arch Surg 1965; 91:29-42 20 Marks J. Anticoagulant therapy in idiopathic occlusions of axillaryvein. BMJ 1956; 1:11-13 21 Wilson JJ, Zahn CA, Newman H. Fibnnolytic therapy for idiopathic subclavian-axillary vein thrombosis. Am J Surg 1990;
159:208-11 22 Colman thrombosis: 11W Hirsh basic Co, M,

immunodeficiency MAC= Mycobacterium carinil pneumonia

virus; avium

CMVcytomegalovirus; LDH lactate


complex; PCP

H1Vh1 dehydrogenase;
Pneumocyatis

PneunwcystLI

percent
syndrome

illness.
described
pleural is very

carinii pneumonia (PCP) occurs in 80 of all patients with acquired immunodeficiency (AIDS) at some time during the course of their Although spontaneous pneumothorax is a well-

J,

Marder

VJ, Salzman

principles Creger

JB Lippincott
23 Rubenstein catheter-induced 1980; 24

and clinical 1987; 1408-10


WE Successful vein pulmonary thrombosis. DM,

EW. Hemostasis and practice. Philadelphia:


therapy Intern for

complication
space causing uncommon. is

of PCP,
inflammation In fact, it has

actual

involvement

of the

and a significant effusion been stated that ifa pleural

steptokinase Arch In:

subclavian SZ. and Lutter Massive deep KS, venous Moeller scanning. 199-200

thrombosis.
embolism.

Med

140:1370-71
Pulmonary WB SaunPhiladelphia: Hasselfeld extremity KA, venous

Coldhaber embolism ders

present, it is probably indicative of a disorder other than PC? In this article, we describe two patients in whom the diagnosis of P carinii infection was made by evaluation of pleural fluid. To our knowledge, identification ofPcarinii in pleural fluid has not been described previously.
effusion

Co, 1985;
McKenna

25

KerrTM,

Roedersheithrombosis
CASE

CASE
1 man with

REPORTS

mer RL,
diagnosed 26 Mukherjee

PJ, et al. Upper

Am J Surg 1990; 160:202-06 CA, Sado Maj AS, Bertoglio MC. Use oflight reflection rheography for diagnosis ofaxillary or subclavisa venous thrombosis. Am J Surg 1991; 161:651-56 27 Pais SO, De Orchis DF, Mirvis SE. Superior vena caval placement of a Kimray-Greenfield filter. Radiology 1987; 165: by duplex D, Andersen

A 23-year-old
weeks

hemophilia cough,

A was dyspnea

examined on exertion,

because fevers,

of 2 and

of a nonproductive

*From
Francisco.

the

Pulmonary

Division

University

of California

at San

1890

Diagnosis

of P carinil Infection

by Identification

of P carin!!

fri

Pleural

Fluid

(Schaumberg

et a!)

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Upper extremity deep venous thrombosis. Underdiagnosed and potentially lethal. M D Black, G J French, P Rasuli and A C Bouchard Chest 1993;103; 1887-1890 DOI 10.1378/chest.103.6.1887 This information is current as of November 16, 2009
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