Üst exstremitede bulgulanan derin venöz tromboz olgularına yaklaşım

Amaç: Üst ekstremite derin venöz trombozları son yıllarda artan invazif vasküler girişimlere paralel olarak daha sıkça karşımıza çıkmaktadır. Bu çalışmada risk faktörleri, bulguları, tanısı ve tedavisi ile klinik gidişatını incelediğimiz üst ekstremite derin venöz tromboz (UEDVT) olgularımızı retrospektif olarak değerlendirmeyi amaçladık. Yöntem: Temmuz 1998 ile Temmuz 2002 tarihleri arasında Doppler ultrasonografı ile tanısı doğrulanan 36 derin venöz trombozlu olgu çalışmamıza dahil edilmiştir. Hastaların 19'u (%52,7) erkek, 17'si (%47,3) kadın olup yaş ortalaması 54 ± 12,3 idi. Olguların 13'ünde (%36,1) santral venöz kateter mevcut olup bu risk faktörü en sık karşılaşılan UEDVT nedeniydi. Bulgular: Tüm hastalar etyolojik sebebe ve risk faktörlerine göre değerlendirilerek, tedavileri düzenlendi. Düşük molekül ağırlıklı heparin (DMAH) ve sonrasında ortalama 6 ay süreyle oral antikoagülan protokolü uygulandı. Tüm hastalar 2 aylık peryodlarla bir yıl süresince poliklinik takibinde tutuldu. Tüm hastalarımız medikal tedaviye iyi yanıt verdi. Altta yatan hastalıklarına bağlı olarak 9 (%25) olgu takip peryotları tamamlanamadan kaybedildi (UEDVT'e sekonder eksitus saptanmadı). Pulmoner emboli komplikasyonu ve nüks DVT görülmedi. Hiçbir olguda takip süresince posttrombotik sendrom gelişmedi. Sonuç: UEDVT'de erken tanı ve tedavi için klinik değerlendirmenin yanısıra RDUS gibi her açıdan avantajlı tanısal görüntüleme yöntemleri büyük önem taşımaktadır. Tedavide amaçlanan; semptomları giderme, nüksleri önleme ve tedavi süresi ile maliyetleri sınırlama amacıyla DMAITların uygulama kolaylığının yanısıra etldnliği ve kanama riskinin azlığı nedeniyle standart heparine tercih edilerek yüz güldürücü sonuçlar alınacağı kanaatindeyiz.

Anahtar Kelimeler:

Venöz tromboz, Üst ekstremite, Heparin, düşük molekül ağırlıklı, Ultrasonografi, doppler, Geriyedönük çalışma

Approach to upper extremity deep vein thrombosis cases

Objective: The incidence of upper limb deep vein thrombosis is rising in paralel with more frequent invasive vascular procedures in recent years. In this study weaimed to evaluate, the upper limb deep vein thrombosis (ULDVT) cases retrospectively according to risk factors, symptoms, diagnosis and clinical course. Method: Between July 1998 and July 2002, we studied 36 deep vein thrombosis cases which were confirmed with Doppler ultrasound. 19 of the patients were men (52.7%) and 17 were women (47.3%) and mean age was 54 i 12.3 years. 13 cases had (36.1%) central venous catheter being the most common ULDVT reason. Results: All patients were evaluated due to etiology and risk factors and their therapies were managed. Protocol included low molecular weight heparin in the acute phase and then oral anticoagulant for 6 months. All patients were followed at outpatient clinic with 2 month intervals for a year. All responded well to treatment. Before completing the follow-up, 9 patients (25%) died of other reasons not secondary to ULDVT and we didn't see any pulmonary embolus complication and recurrent DVT. None of the cases had postthrombotic syndrome during follow-up. Conclusion: Diagnostic imaging methods such as RDUS, which has many avdan-tages, are very important for early diagnosis and therapy of ULDVT, besides the clinical evaluation. We suggest that LMWH must be preferred to standart heparin therapy because of its effectiveness, rare hemorrhage risk and easy usage to relieve symptoms, prevent recurrences, shorten the therapy period and decrease the costs.

Keywords:

Venous Thrombosis, Upper Extremity, Heparin, Low-Molecular-Weight, Ultrasonography, Doppler, Retrospective Studies,

PDF

___

1. Donayre CE, White GH, Mehringer SM, Wilson SE. Pathogenesis determines late morbidity of axillosubclavian vein thrombosis. Am J Surg 1986; 152: 179-184.
2. Albrechtsson U, Anderson J, Einarsson E et al. Streptokinase treatment of deep venous thrombosis and the post thrombotic syndrome. Arch Surg 1981; 116:33-37.
3. Mustafa S, Stein PD, Patel KC et al. Upper extremity deep venous thrombosis. Chest 2003; 123: 1953-1956.
4. Schimp VL, Munkarah AR, Morris RT, Deppe G, Malone J Jr. Upper extremity deep vein thrombosis associated with indwelling peripheral venous catheters in gynecology oncology patients. Gynecol Oncol 2003; 89: 301-305.
5. Abufalia O, Sherer DM, DeEulis TG et al. Ultrasonographic diagnosis of catheter induced combined subclavian and jugular vein thrombosis. Am J Critical Care 1995; 4: 140-142.
6. Grassi CJ, Polak JF. Axillary and subclavian vein thrombosis: follow-up evaluation with color Doppler flow US and venography. Radiology 1990; 175:651- 654.
7. Shah MK, Black-Schaffer RM. Treatment of upper limb deep vein thrombosis with low molecular weight heparin. Am J Phys Med Rehabil 2003; 82: 415-417.
8. Becker DM, Philbrick JT, Walker FB. Axillary and subclavian venous thrombosis: prognosis and treatment. Arch Intern Med 1991; 151: 1934-1943.
9. Shah MK, Burke DT, Shah SH. Upper-extremity deep vein thrombosis. South Med J 2003; 96: 669-672.
10.Turpie AG, Chin BS, Lip GY. Venous thromboembolism: pathophysiology, clinical features, and prevention. BMJ 2002; 19: 325: 887-890.
11. Hill SL, Berry RE. Subclavian vein thrombosis: a continuing challange. Surgery 1990; 108: 1-9.
12.Baarslag HJ, van Beek EJ, Koopman MM, Reekers JA. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Ann Intern Med 2002; 136: 865-872.
13. Seçil M, Gökta Y, Dicle O, Çatalyürek H, Açıkel Ü. Color Doppler Sonography in Detection of Deep Vein Thrombosis in Upper Extremitis. Turkish J Thorac and Cardiovasc Surg 2000; 8: 808-811.
14.Gooding GAW, Woodruff AYN. Color Doppler imaging in the subclavian – axillary region and upper extremity. Clinical Imaging 1994; 18: 165-172.
15. Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Curr Opin Pulm Med 1999; 5: 222-226.
16.Bern MM, Lokich JJ, Wallach SR et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. Ann Intern Med 1990; 112: 423-428.
17. Lensing AWA, Prins MH, Davidson BL et al. Treatment of deep vein thrombosis with low molecular weight heparins: A metaanalysis. Arch Intern Med 1995; 155: 601-607.
18. Koopman Maria MW, Prandoni P, Piovella F et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. Jn Eng Med 1996; 334: 682-687.
19. Lindmarker P, Holmstrom M, Granqvist S et al. Comparison of once-daily subcutaneous Fragmin with continuous intravenous unfractionated heparin in the treatment of deep vein thrombosis. Thromb Haemost 1994; 72: 186-190.
20.Kalodiki E, Nicolaides AN. Superficial thrombophlebitis and low-molecular-weight heparins. Angiology 2002; 53: 659-663.
21.Hirsh J, Fuster V. Guide to anticoagulant therapy: Part II. Oral anticoagulants. Circulation 1994; 89:1469-1480.