Thoracic Paget- Schroetter Syndrome Central Venous Obstruction - - PowerPoint PPT Presentation

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Jun 06, 2023 106 likes •185 views

4/15/2016 These are ALL examples of T-CVO Thoracic Paget- Schroetter Syndrome Central Venous Obstruction (T-CVO) Cellulitis in swollen arm w/ AVF A New Look at an Old Problem but each one is a different Bart Dolmatch, MD, FSIR AVF

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Thoracic Central Venous Obstruction (T-CVO) A New Look at an Old Problem

Bart Dolmatch, MD, FSIR

Cellulitis in swollen arm w/ AVF Paget- Schroetter Syndrome

These are ALL examples of T-CVO …but each one is a different

AVF Dilation

There has never been a universal set

f reporting standards for T-CVO

So we really don’t know much about prevalence, natural history, treatment, and outcomes* *The “literature” stinks!

What if We Didn’t Have Reporting Standards for PAD? Would we say, “PAD is a complicated problem, intervention gives mixed results, and we don’t know what to do?”

(This is what we say about T-CVO!)

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PAD REPORTING SYSTEMS For SYMPTOMS PAD ANATOMIC CLASSIFICATION

Why are there are NO Reporting Standards for Thoracic CVO?

Birth of the Central Vein work Group (CVWG)

Representatives from

Interventional Radiology Vascular Surgery Transplant Surgery Nephrology Hematology/Oncology Cardiology Pediatrics Clinical Anatomy

20 members (+/-) 14 Conference Calls – 2 yrs

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Soc. Interventional Radiology
Soc. Vascular Surgery
Am. College of Surgeons

Vascular Access Soc. of the Americas

Am. Soc. of Diagnostic and Interv. Nephrologists
Am. Soc. of Pediatric Hematologists and Oncologists
Am. Heart Assoc.

…and many other org’s and societies

Members and/or Officers from…

Do we all Know Thoracic Central Vein Anatomy? Where does the Subclavian Vein begin?

1st rib

*

SCV starts here SCV starts here Central IJV’s start here

The « central venous» segment of the Internal Jugular Vein starts at the superior margin of 1st rib Is the Internal Jugular Vein a “Central Vein?”

Thoracic “Central Veins”

…and the suprahepatic IVC)

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“Anatomically” Important Features of All T-CVO’s

1. How “obstructed?”

Stenosis: Up to 99% luminal narrowing Occlusion: 100% obstruction

2. Venous flow or AV access flow?
3. “Type” of Obstruction?

Anatomy of Thoracic CVO

Type 1a Type 1b Type 2a Type 2b Type 3 Type 4 Type 5 Type 6

Symptoms

1. Swelling (Yes/No)
2. Pain (Yes/No)
3. Onset of dyspnea (Yes/No)
4. Onset of CNS symptoms (Yes/No)

Headache, Dizziness, Altered vision, Altered hearing, Seizure, Other (specify)

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Signs

1. Swelling – measure and record in mm’s

Unilateral

Bilateral/head-neck

2. Skin changes:

Skin discoloration of the affected arm

Lymphatic blistering or weeping

Stasis ulcers

Infection (cellulitis, abscess, or purulent drainage)

Non-healing wounds or incisions

3. Venous findings:

a. Ectatic venous collaterals (exam and/or imaging) b. Venous thrombosis (exam and/or imaging) c. Phlebitis (exam)

Duration of Symptoms Reported in # of days (not weeks or months)

1-14 days (Acute) 15-28 days (Sub-acute) >28 days (Chronic)

Performance Status Due to T-CVO

0. Asymptomatic: No change in performance
I. Symptomatic: No change in performance
II. Symptomatic : Impaired; some restriction in physical

exercise, self-care and/or performance of some daily activities but not disabled

III. Symptomatic : Disabled; cannot exercise, and

capable of only limited self-care and daily activities

IV. Symptomatic: Incapacitated; incapable of self-care

and daily activities

3 Functional Limitations

1.

Problems with cannulation of an upper body hemodialysis access

2.

Inability to place venous access (venous catheter or AV access) at an intended site.

3.

T-CVO that necessitates recanalization or intervention by any method (e.g., guide wire recanalization,

angioplasty, stent placement, or surgery)

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T-CVO Reporting Highlights

Define Anatomy

Stenosis, occlusion Anatomy of Obstruction

Symptoms (4) Signs (3) Duration Performance Status Functional Limitation

Paget- Schroetter Syndrome

Occlusion Unilateral with Venous Flow Type 1b Symptoms: Left Arm Swelling, Pain (no dyspnea or CNS) Signs: Swelling, Plethora (no venous findings) R Arm 102mm L Arm 128mm Duration: 2 Days (Acute) Performance Status: III. Symptomatic : Disabled; cannot exercise, and capable of only limited self-care and daily activities Functional Limitation: None

Cellulitis in swollen arm w/ AVF

Occlusion Unilateral with AV access flow Type 4 Symptoms: Right Arm Swelling, Pain (no dyspnea or CNS) Signs: Swelling, Erythema, cellulitis (no venous findings) R Arm 134mm L Arm 112mm Duration: 20 Days (Sub Acute) Performance Status: III. Symptomatic : Disabled; cannot exercise, and capable of only limited self-care and daily activities Functional Limitation: Cannot cannulate AVF

Status of T-CVO Reporting Standards

Endorsed by the Society of Interventional Radiology as a formal Reporting Standards Project

Draft manuscript nearly completed

1. Co-publication by JVIR and JVS
2. Many other groups are interested in “endorsing” this work.
3. Publication planned before summer 2016

Further work has begun on lesions, collaterals, etiologies.

Nomenclature of T-CVO for EHR and Global Lexicon

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