link
Bookmarks
Upper Extremity and Central Venous Intervention
Brandt C. Wible, MD; Scott M. Brannan, MD; Stephan Wicky, MD
To access 4,300 diagnoses written by the world's leading experts in radiology, please log in or subscribe.Log inSubscribe

KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        TERMINOLOGY

        • Synonyms

          • Brachiocephalic vein = innominate vein
            • Brachiocephalic vein is preferred term
            • Innominate veins bilateral, unlike innominate artery
        • Definitions

          • Axillosubclavian vein thrombosis (ASVT)
            • Primary ASVT
              • a.k.a. Paget-Schroetter syndrome, effort thrombosis, venous thoracic outlet syndrome
              • Thrombosis/stenosis/occlusion of axillary/subclavian vein
              • Occurs in young adults following repetitive exercises (e.g., swimming, weight-lifting) or prolonged shoulder abduction
                • M:F = 2:1
                • 15-35 years old
                • > 70% of cases involve dominant upper extremity
              • Associated with mechanical vein compression at costoclavicular junction
                • Hypertrophied/broad subclavius or anterior scalene muscle extrinsically compress vein
                • Repetitive trauma leads to thickening and fibrosis
                • Injured venous intima promotes thrombus formation
                • Clavicular and 1st-rib anomalies are rare
              • Clinical symptoms/physical findings
                • Sudden severe unilateral upper extremity swelling resulting from venous hypertension
                • Subocclusive thrombosis and resolution common before ultimate event
                • Prominent collateral veins on arm/shoulder/chest quickly develop on affected side
                • Acute symptoms of heaviness, aching, and swelling improve if ignored/untreated
                • Symptoms return with resumption of activity
                • 10% incidence of pulmonary embolism
            • Secondary ASVT
              • Much more common than primary form, accounting for 80% of ASVT
              • Etiology associated with inciting venous injury
                • Long-term central venous catheters/pacemakers primary cause (> 60%); increasing incidence
                • Malignancy/adenopathy (25-29%)
                • Trauma/surgery
                • Radiation therapy
              • May also involve brachiocephalic veins
              • Affected population older and less healthy
          • Superior vena cava obstruction (SVCO)
            • Malignant etiologies: Most common
              • Responsible for 60-85% of SVCO cases
              • Most common etiologies: Bronchogenic carcinoma, small cell lung cancer, lymphoma, mediastinal metastasis
              • Symptoms typically worse than benign etiologies
                • Rapid onset limiting development of collaterals
                • Central location involving SVC just superior to right atrium, potentially involving azygous vein
            • Benign etiologies: Increasing
              • Most common etiologies
                • Chronic/frequent central venous catheters
                • Transvenous pacemaker wires
                • Fibrosing mediastinitis
            • Superior vena cava syndrome (SVCS)
              • Clinical manifestations of SVCO
                • Neck swelling (100%), facial edema (48-82%), distended neck veins (63%), dyspnea (54-83%), cough (22-58%)
                • Less common is hoarseness, headache, syncope, dizziness, phrenic nerve paresis, chest pain
              • Grade 4 life-threatening SVCS (5% of SVCS presentations)
                • Significant laryngeal edema or cerebral edema, or hemodynamic compromise
                • Requires emergent endovascular stent placement
                • Radiation therapy not indicated for 1st-line treatment if endovascular stenting is feasible
              • If thrombotic etiology (28% of SVCS): Anticoagulation is 1st-line treatment, effective in 88% of cases when started within 5 days
              • If infectious etiology: Antibiotic coverage is 1st-line treatment
        • Anatomy

          • Venous anatomy of involved veins
            • Upper extremity deep veins
              • Brachial (usually paired), axillary, subclavian
            • Upper extremity veins
              • Cephalic, basilic, median basilic
                • Basilic vein frequently joins brachial vein
                • Brachial vein terminates in axillary vein
              • Axillary vein starts at border of teres major muscle
                • Becomes subclavian vein at 1st rib outer edge
            • Mediastinal veins
              • Subclavian/internal jugular veins join to form brachiocephalic veins
              • Brachiocephalic veins join to form SVC
                • SVC posterior to manubrium/sternum on right
              • Collateral drainage with chronic SVC occlusion
                • Azygos system; unnamed neck/chest collaterals
          • DSA minimizes required volume of contrast media

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Special Considerations

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Complications

                            • Expected Outcome

                              Selected References

                              1. Breault S et al: Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes : long-term follow-up. Eur Radiol. 27(1):97-104, 2016
                              2. Agarwal AK: Endovascular interventions for central vein stenosis. Kidney Res Clin Pract. 34(4):228-32, 2015
                              3. Collin G et al: Central venous obstruction in the thorax. Clin Radiol. 70(6):654-60, 2015
                              4. Quaretti P et al: Dialysis catheter-related superior vena cava syndrome with patent vena cava: long term efficacy of unilateral Viatorr stent-graft avoiding catheter manipulation. Korean J Radiol. 15(3):364-9, 2014
                              5. Agarwal AK: Central vein stenosis. Am J Kidney Dis. 61(6):1001-15, 2013
                              6. Iafrati M et al: Radiofrequency thermal wire is a useful adjunct to treat chronic central venous occlusions. J Vasc Surg. 55(2):603-6, 2012
                              7. Canales JF et al: Single center experience with percutaneous endovascular repair of superior vena cava syndrome. Catheter Cardiovasc Interv. 77(5):733-9, 2011
                              8. Cho TH et al: The role of stenting the superior vena cava syndrome in patients with malignant disease. Angiology. 62(3):248-52, 2011
                              9. Lepper PM et al: Superior vena cava syndrome in thoracic malignancies. Respir Care. 56(5):653-66, 2011
                              10. Thompson JF et al: Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol. 34(5):903-10, 2011
                              11. Da Ines D et al: Cardiac tamponade after malignant superior vena cava stenting: two case reports and brief review of the literature. Acta Radiol. 51(3):256-9, 2010
                              12. Guzzo JL et al: Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis. J Vasc Surg. 52(3):658-62, 2010
                              13. Illig KA et al: A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 51(6):1538-47, 2010
                              14. Greillier L et al: [Malignant superior vena cava syndrome: why refrain from vascular stenting?.] Rev Mal Respir. 26(7):719-21, 2009
                              15. Lanciego C et al: Endovascular stenting as the first step in the overall management of malignant superior vena cava syndrome. AJR Am J Roentgenol. 193(2):549-58, 2009
                              Related Anatomy
                              Loading...
                              Related Differential Diagnoses
                              Loading...
                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Procedure

                                  • Post Procedure

                                    TERMINOLOGY

                                    • Synonyms

                                      • Brachiocephalic vein = innominate vein
                                        • Brachiocephalic vein is preferred term
                                        • Innominate veins bilateral, unlike innominate artery
                                    • Definitions

                                      • Axillosubclavian vein thrombosis (ASVT)
                                        • Primary ASVT
                                          • a.k.a. Paget-Schroetter syndrome, effort thrombosis, venous thoracic outlet syndrome
                                          • Thrombosis/stenosis/occlusion of axillary/subclavian vein
                                          • Occurs in young adults following repetitive exercises (e.g., swimming, weight-lifting) or prolonged shoulder abduction
                                            • M:F = 2:1
                                            • 15-35 years old
                                            • > 70% of cases involve dominant upper extremity
                                          • Associated with mechanical vein compression at costoclavicular junction
                                            • Hypertrophied/broad subclavius or anterior scalene muscle extrinsically compress vein
                                            • Repetitive trauma leads to thickening and fibrosis
                                            • Injured venous intima promotes thrombus formation
                                            • Clavicular and 1st-rib anomalies are rare
                                          • Clinical symptoms/physical findings
                                            • Sudden severe unilateral upper extremity swelling resulting from venous hypertension
                                            • Subocclusive thrombosis and resolution common before ultimate event
                                            • Prominent collateral veins on arm/shoulder/chest quickly develop on affected side
                                            • Acute symptoms of heaviness, aching, and swelling improve if ignored/untreated
                                            • Symptoms return with resumption of activity
                                            • 10% incidence of pulmonary embolism
                                        • Secondary ASVT
                                          • Much more common than primary form, accounting for 80% of ASVT
                                          • Etiology associated with inciting venous injury
                                            • Long-term central venous catheters/pacemakers primary cause (> 60%); increasing incidence
                                            • Malignancy/adenopathy (25-29%)
                                            • Trauma/surgery
                                            • Radiation therapy
                                          • May also involve brachiocephalic veins
                                          • Affected population older and less healthy
                                      • Superior vena cava obstruction (SVCO)
                                        • Malignant etiologies: Most common
                                          • Responsible for 60-85% of SVCO cases
                                          • Most common etiologies: Bronchogenic carcinoma, small cell lung cancer, lymphoma, mediastinal metastasis
                                          • Symptoms typically worse than benign etiologies
                                            • Rapid onset limiting development of collaterals
                                            • Central location involving SVC just superior to right atrium, potentially involving azygous vein
                                        • Benign etiologies: Increasing
                                          • Most common etiologies
                                            • Chronic/frequent central venous catheters
                                            • Transvenous pacemaker wires
                                            • Fibrosing mediastinitis
                                        • Superior vena cava syndrome (SVCS)
                                          • Clinical manifestations of SVCO
                                            • Neck swelling (100%), facial edema (48-82%), distended neck veins (63%), dyspnea (54-83%), cough (22-58%)
                                            • Less common is hoarseness, headache, syncope, dizziness, phrenic nerve paresis, chest pain
                                          • Grade 4 life-threatening SVCS (5% of SVCS presentations)
                                            • Significant laryngeal edema or cerebral edema, or hemodynamic compromise
                                            • Requires emergent endovascular stent placement
                                            • Radiation therapy not indicated for 1st-line treatment if endovascular stenting is feasible
                                          • If thrombotic etiology (28% of SVCS): Anticoagulation is 1st-line treatment, effective in 88% of cases when started within 5 days
                                          • If infectious etiology: Antibiotic coverage is 1st-line treatment
                                    • Anatomy

                                      • Venous anatomy of involved veins
                                        • Upper extremity deep veins
                                          • Brachial (usually paired), axillary, subclavian
                                        • Upper extremity veins
                                          • Cephalic, basilic, median basilic
                                            • Basilic vein frequently joins brachial vein
                                            • Brachial vein terminates in axillary vein
                                          • Axillary vein starts at border of teres major muscle
                                            • Becomes subclavian vein at 1st rib outer edge
                                        • Mediastinal veins
                                          • Subclavian/internal jugular veins join to form brachiocephalic veins
                                          • Brachiocephalic veins join to form SVC
                                            • SVC posterior to manubrium/sternum on right
                                          • Collateral drainage with chronic SVC occlusion
                                            • Azygos system; unnamed neck/chest collaterals
                                      • DSA minimizes required volume of contrast media

                                    PREPROCEDURE

                                    • Indications

                                      • Contraindications

                                        • Preprocedure Imaging

                                          • Special Considerations

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcome

                                                          Selected References

                                                          1. Breault S et al: Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes : long-term follow-up. Eur Radiol. 27(1):97-104, 2016
                                                          2. Agarwal AK: Endovascular interventions for central vein stenosis. Kidney Res Clin Pract. 34(4):228-32, 2015
                                                          3. Collin G et al: Central venous obstruction in the thorax. Clin Radiol. 70(6):654-60, 2015
                                                          4. Quaretti P et al: Dialysis catheter-related superior vena cava syndrome with patent vena cava: long term efficacy of unilateral Viatorr stent-graft avoiding catheter manipulation. Korean J Radiol. 15(3):364-9, 2014
                                                          5. Agarwal AK: Central vein stenosis. Am J Kidney Dis. 61(6):1001-15, 2013
                                                          6. Iafrati M et al: Radiofrequency thermal wire is a useful adjunct to treat chronic central venous occlusions. J Vasc Surg. 55(2):603-6, 2012
                                                          7. Canales JF et al: Single center experience with percutaneous endovascular repair of superior vena cava syndrome. Catheter Cardiovasc Interv. 77(5):733-9, 2011
                                                          8. Cho TH et al: The role of stenting the superior vena cava syndrome in patients with malignant disease. Angiology. 62(3):248-52, 2011
                                                          9. Lepper PM et al: Superior vena cava syndrome in thoracic malignancies. Respir Care. 56(5):653-66, 2011
                                                          10. Thompson JF et al: Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol. 34(5):903-10, 2011
                                                          11. Da Ines D et al: Cardiac tamponade after malignant superior vena cava stenting: two case reports and brief review of the literature. Acta Radiol. 51(3):256-9, 2010
                                                          12. Guzzo JL et al: Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis. J Vasc Surg. 52(3):658-62, 2010
                                                          13. Illig KA et al: A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 51(6):1538-47, 2010
                                                          14. Greillier L et al: [Malignant superior vena cava syndrome: why refrain from vascular stenting?.] Rev Mal Respir. 26(7):719-21, 2009
                                                          15. Lanciego C et al: Endovascular stenting as the first step in the overall management of malignant superior vena cava syndrome. AJR Am J Roentgenol. 193(2):549-58, 2009