Risk sk s strat tratif ific icat ation a and nd inc ncidenc - - PowerPoint PPT Presentation

Risk sk s strat tratif ific icat ation a and nd inc ncidenc nce o e of f acute c e complic icat atio ions s in n upper e r extrem remit ity d deep ep v vein in th thrombosis sis (U (UEDVT) ) patie tient nts. s.

• Dr. Santosh Yatam Ganesh MBBS, MPH.,

Mentors: Dr. Khalid J. Qazi MD, MACP .,

• Dr. Paul Anain MD, FACS.

VI.XII.MMXIII

Overview of the presentation

• Purpose of research
• Epidemiology
• Introduction to Upper extremity deep vein thrombosis

(UEDVT)

• Research design
• Results
• Discussion
• Conclusion

Purpose of research

• To understand the risk factors of the UEDVT;
• To identify complications rate due to UEDVT

during the hospital stay;

• This study will help optimize patient care and

decrease the incidence of UEDVT;

Epidemiology

• Annual incidence is 0.4-1 per 10,000 people;
• Of all the deep vein thrombosis cases, nearly 10% involve upper

extremity;

• Incidence increasing;

– Peripherally inserted central catheter(PICC), – Central venous catheter(CVC), – Malignancy.

• Complications are rare;

– Pulmonary embolism, – SVC syndrome, – Post thrombotic venous insufficiency.

Introduction to Upper extremity deep vein thrombosis (UEDVT)

• Defined as a thrombus in any of the upper

extremity deep veins.

• Deep veins of upper extremity: Radial, Ulnar, Brachial,

Axillary, Subclavian, Internal Jugular.

• Superficial veins of upper extremity: Digital, Metacarpal,

Cephalic, Basilic, Median. Primary Secondary

• Venous thoracic outlet

syndrome,

• Effort-related thrombosis

(Paget–Schroetter syndrome) or

• Idiopathic.
• PICC,
• CVC,
• Malignancy.

• The Computerized Registry of Patients with Venous

Thromboembolism (RIETE):

– Multicenter study involving Spain, France, Italy, Israel, Argentina – Data released by CHEST in 2008 – 11564 total. 512 had UEDVT. – Significant findings compared to lower extremity DVT:

• younger age,
• Lower BMI,
• association with Cancer,
• higher overall mortality.

– Also more association with PE compared to without UEDVT.

• 9% had PE

• At University of California
• Recent article
• One year study
• Out of 373 patients underwent Ultrasound 94 had DVT
• Mean age 51
• 46(49%) had malignancy
• Pain swelling common symptoms
• 11 patients had PE
• Subclavian : most common vein

• One year data from 12 hospitals.
• Total 483. Out of which 69 had UEDVT
• Significantly associated with Central lines, ICU admissions
• No difference in 30 days, 6 months and 1year outcomes
• No statistical difference in association to cancer

UEDVT LEDVT 16 per 10,000 71 per 10,000 AGE: 59 66

Research Question

• To find the risk factors in patients with upper

extremity deep venous thrombosis;

• To find the incidence of acute complications

related to upper extremity deep venous thrombosis;

Methodology

• Study populations was identified using ICD9 codes.
• Either admitting diagnosis or diagnosed during the hospital stay.
• Retrospective chart review.
• Data from last three years.
• At Sisters of charity hospital and Mercy hospital of Buffalo.
• Used EMR and paper charts.

Inclusion criteria :

• Adults age above 18.
• Patients with newly diagnosed upper extremity deep vein

thrombosis.

• Diagnosis during hospitalization or at admission.
• Confirmatory evidence of diagnosis.

Exclusion criteria :

• Patients without confirmatory evidence in the

imaging will be excluded.

• Patients who have chronic deep vein thrombosis

with duration greater than 60 days.

• Other thrombosis like in lower extremity.

Total charts : 327 Thrombosis in UE: 272 UEDVT: 187 Superficial vein thrombosis: 85 Excluded: 55

Results

Age Distribution for DVT patients only

BMI N % <18.49 7 3.7 18.5-24.99 60 32.1 25-29.99 55 29.4 30-39.99 65 34.76 Mean Weight 80.8 Kgs Mean BMI 28.39

3.7 32.1 29.4 34.7

<18.49 18.5-24.99 25-29.99 30-39.99

90 85 84 42 10 20 30 40 50 60 70 80 90 100 Axillary Subclavian Brachial Internal Jugular

Veins

148 59 17 24 20 40 60 80 100 120 140 160 Swelling Pain Erythema Other

Presenting Signs/Symptoms

44(24%) 17( 9%) 126(67%)

DVT Prophylaxis

NO Arrived YES

Frequency % Cumulative % PICC 82 43.9 43.9 CVC/Dialysis/Mediport 34 18.2 62.0 Pacemaker/AICD 14 7.5 69.5 Unidentified 12 6.4 75.9 none 45 24.1 Total 187 100.0 100

Co-Morbidities N Percentage

HTN 121 61.7 Cancer 63 33.7 Dyslipidemia 61 32.6 COPD 58 31 DM 56 29.9 CHF 53 28.3 Sepsis 51 27.3 CAD 46 24.6 Hypothyroidism 38 20.3 CKD 37 19.8 CVA/TIA 20 10.7 H/o Hypercoagulability 18 9.6 Mechanical 7 3.7

N % PE 14 7.5 SVC 9 4.8 Other 2 1.1 None 162 86.6 Total 187 100

7.5% 4.8% 1.1% 86.6%

COMPLICATIONS DURING THE HOSPITALIZATION

PE SVC Other None

Comparing Upper extremity deep venous thrombosis with superficial venous thrombosis

<40 41-50 51-60 61-70 >71 Total Deep VT 12 24 31 37 83 187 Superficial VT 9 10 8 15 43 85 Total 21 34 39 52 126 272

Symptoms DVT(%) SVT(%) p Value Relative risk CI Swelling 148(79) 69(81) 0.699 0.975 .85-1.1 Pain 59(31) 17(20) 0.04 1.57 1.1-2.5 Erythema 17(9) 8(9.4) 0.932 0.96 0.43-2.32

Lines frequency in Deep venous thrombosis and Superficial venous thrombosis patients

PICC CVC/Dialysis /Mediport Pacemaker/ AICD Unidentified None

DVT 82 34 14 12 45 SVT 25 9 2 2 47 Total 107 43 16 14 92

COMORBIDITY DVT(%) SVT(%) p-value RR CI HTN 121(65) 51(60) 0.45 1.07 0.88-1.32 SMOKING 92(49) 38(44) 0.492 1.10 0.83-1.45 CANCER 63(33) 10(12) <.0001 2.86 1.54-5.30 DYSLIPIDEMIA 61(33) 26(31) 0.73 1.06 0.729-1.56 COPD 58(31) 21(25) 0.28 1.25 0.81-1.92 DM 56(30) 26(31) 0.91 0.97 0.66-O.852 CHF 53(28) 18(21) 0.21 1.33 0.83-2.14

COMORBIDITY DVT(%) SVT(%) p-value RR CI SEPSIS 51(27) 19(22) 0.39 1.2 0.77-1.93 CAD 46(24) 16(19) 0.29 1.3 0.78-2.17 H/o DVT 39(20) 7(8) 0.017 2.53 1.18-5.42 HYPOTHYROIDIS M 38(20) 8(9) 0.004 2.15 1.05-4.42 CKD 37(20) 5(6) 0.004 3.36 1.37-8.25 CVA/TIA 20(11) 8(9) 0.74 1.1.3 0.522-2.47 H/o Hypercoagulable 18(10) 2(3) .05 4.09 0.97-17.23

Frequency of Complications in hospitals

For Pulmonary embolism comparing DVT and SVT p Value is 0.211 rr: 2.12, CI: 0.62-7.18

p Value: 0.013, rr: 3.78 CI: 1.17-12.2 Complications during hospitalization comparing Deep VT vs. Superficial VT

Discussion

Demographics:

• Age

– 65% of patients are above the age of 65. – Mean age is higher compared to RIETE study.

• Gender:

– No major difference.

• Race:

– More common in Whites. – Results are similar to the study done at University at California.

• BMI:

– Increase in BMI increases risk for UEDVT. – Average weight is higher than other studies.

Risk Factors:

• Smoking:

– Nearly 50%.

• HTN, COPD, Cancer, Dyslipidemia:

– In more than 1/3rd of patients.

• CHF, Sepsis, CAD:

– In more than 1/4th of the patients. Investigation tool:

• US is the most commonly used diagnostic modality

– Sensitivity75-95%. – Specificity 95-98%. Symptoms:

• Swelling is the most common symptom.

Lines:

• PICC, CVC, PACEMAKER/AICD: 75%.
• 2/3rd of patients were on DVT prevention prophylaxis with anticoagulants.

Comparing UEDVT and Superficial vein:

• Pain is associated with UEDVT;
• Lines are important risk for UEDVT compared to SVT;
• History of previous DVT increases risk for future DVT compared to

SVT;

• Cancer, CKD and Hypothyroidism are associated with UEDVT than

SVT;

• Overall more complications from UEDVT during hospital stay;

• Study done by Liviu et al (publishes in Chest in 2008) it showed

statistically significant association of hypothyroidism and DVT. No studies particularly on UEDVT.

• Daneschvar et al study has shown the association between the

UEDVT and CKD. They compared the 268 patients with CKD with 4,307 patients with preserved kidney function. 30% Patient with CKD had UEDVT compared to 10 without ckd.

• A study at University of California by Jung-Ah lee on 373 UEDVT

patients cancer was diagnosed in 48% of patients. We had lesser number of patients with cancer however hospitals we conducted study does not have dedicated cancer floors.

Conclusions

• Clinical profile of patients with UEDVT and Superficial thrombosis were

variable.

• Suspect UEDVT compared to Superficial thrombosis

– Swelling – Cancer – CKD – Hypothyroidism – With Lines

• Patients with UEDVT overall experience more complications than

Superficial vein thrombosis during the hospital stay.

• First study to find differences in risk factors for Deep vein thrombosis vs

Superficial thrombosis in Upper extremity.

References

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Special thanks Mentors: Dr. Qazi & Dr. Anain. Guidance: Dr. Woodman & Dr. Tourbaf. Acknowledgement Statistician: Dr. Satchidanand.