Letter to the Editor: Short Reports
275
Upper Extremity Deep Vein Thrombosis and Pulmonary Embolus after Radial Forearm Free Flap: A Case Report and Literature Review Jon Ver Halen, MD2
Sandeep Samant, MBBS1
1 Department of Otolaryngology/Head and Neck Surgery, University of
Tennessee Health Science Center, Memphis, Tennessee 2 Department of Plastic and Reconstructive Surgery, Baptist Cancer Center/Vanderbilt Ingram Cancer Center, Memphis, Tennessee
Address for correspondence Jon Ver Halen MD, FACS, 6215 Humphreys Blvd, Ste 209, Memphis, TN 38120 (e-mail: [email protected]).
J Reconstr Microsurg 2014;30:275–278.
Background Deep vein thrombosis (DVT) and its associated complications such as pulmonary embolism (PE) are well-known causes of morbidity and mortality in the surgical intensive care unit settings. The presentation, diagnosis, and management of lower extremity DVT (LEDVT) are well documented in the literature. However, the same is not true of those that occur in the upper extremities.1 Upper extremity DVT (UEDVT) are less common than LEDVT , and usually asymptomatic until their complications arise. Risk factors for UEDVT differ from those of LEDVT, and include presence of a central venous catheter, cancer, and immobility.1,2 The first line therapy for UEDVT is systemic anticoagulation with low molecular weight heparin and long-term vitamin K antagonist therapy. Although less than in LEDVT, there is significant morbidity and mortality related to UEDVT, including PE and postthrombotic syndrome. We present a case of UEDVT that occurred in a head and neck cancer patient following relative immobility subsequent to radial forearm free flap harvest from his left arm.
Case Report Our patient is a 57-year-old Caucasian male who had undergone a left hemiglossectomy for radiation-induced sarcoma. At the time of his surgical excision, he had a radial forearm free flap (RFFF) taken from his left forearm that was used for reconstruction of his glossectomy defect. RFFF harvest was accomplished under 250 mm Hg upper arm tourniquet control for 47 minutes. Only the main radial artery pedicle and venae comitantes were used, thus excluding the cephalic vein from harvest. He also had a tracheostomy tube placed at the time of the operation. His course was complicated by a pulmonary embolism (PE) on postoperative day 8.
received September 15, 2013 accepted after revision October 6, 2013 published online January 7, 2014
The patient’s tracheostomy tube had been capped on day 5 and he had no respiratory distress. However, he had marginal oxygen saturations with occasional desaturations into the 80% range. He was started on supplemental oxygen through nasal cannula. A chest X-ray showed bibasilar atelectasis, and he was given an incentive spirometer. There were no intravenous lines of any kind placed in the left arm, and only a peripherally-inserted intravenous line on the right arm. The patient had been meeting with the physical therapy daily since his operation. However, his therapy course was difficult secondary to left arm pain. As a result of this pain, the patient was relatively immobile and had difficulty moving his left arm. In addition, a noncircumferential wound vaccumassisted closure device (VAC) at 125 mm Hg of continuous pressure and volar intrinsic-plus (Sammons Preston plaster, Lakewood, NJ) forearm splint was in place on the left forearm, which added a challenge to mobility. His respiratory status remained unchanged until the evening of day 8, when he started to complain of mild chest pain along with occasional desaturation into the 80% range on supplemental oxygen. A computed tomography (CT) pulmonary angiogram was performed, which showed pulmonary artery embolisms that involved the left main pulmonary artery and the right segmental pulmonary arteries (►Fig. 1). Ultrasonography was negative for lower extremity DCT (LEDVT), but revealed a thrombus located in the left brachial vein. The patient had been on low dose of subcutaneous heparin throughout his hospitalization for prophylaxis of DVT. He was also maintained on 81 mg of aspirin per free flap protocol. He did not have a central venous catheter (CVC) at any time during his hospitalization. After his PE was detected, he was treated initially with a therapeutic heparin drip and transitioned to low molecular weight heparin (LMWH), and
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1361845. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Joshua Wood, MD1
Letter to the Editor: Short Reports
Fig. 1 A computed tomography pulmonary angiogram was performed, which demonstrated pulmonary artery embolisms involving the left main pulmonary artery and the right segmental pulmonary arteries. Figure depicts thrombus located in the left main pulmonary artery.
enoxaparin therapy 2 days later. The patient did not have any further chest pain, respiratory distress, or complications from his pulmonary emboli. The patient had further surgery for skin graft to be placed at the RFFF donor site, so we elected to continue therapy with enoxaparin. He was discharged from the hospital 10 days later. Following his skin graft procedure, he was transitioned to warfarin therapy. Hypercoagulable workup as an outpatient was negative for any routine abnormality. Items for screening included activated protein C resistance (i.e., factor V Leiden deficiency); prothrombin G20210A mutation; deficiencies of antithrombin III, protein C, protein S; hyperhomocysteinemia; and antiphospholipid antibody syndrome.
Discussion Upper extremity DVT (UEDVT) accounts for only 1 to 10% of all DVT, and occur at the rate of 3 per 100,000 in the general population.1,3,4 However, this is thought to be an underestimate because it only reflects the symptomatic and documented UEDVT.2,4 UEDVT may occur in the following veins (in descending order of frequency): the subclavian vein, internal jugular vein, axillary vein, and the brachial vein. Oftentimes, the DVT is found in more than one segment of the veins at a time.4,5 The risk factors for UEDVTs differ from those of its counterparts in the lower extremities. Known risk factors for LEDVT such as surgery, advancing age, and obesity were not seen as risk factors for UEDVT.6 Instead, risk factors for UEDVT include cancer, history of venous thromboembolism, concomitant LEDVT, the presence of a CVC, hypercoagulable states, contraindications for anticoagulation, and immobilization for more than 3 days.1,2 The single most important factor is the presence of CVC, which accounts for 45 to 72% of all UEDVT.1,5,6 Cancer is also a strong risk factor. Most cancer Journal of Reconstructive Microsurgery
Vol. 30
No. 4/2014
patients are undergoing chemotherapy, hormone therapy, radiotherapy, surgery, have indwelling CVC and are immobile to some degree. All of these lead to greater propensity for UEDVT formation. Joffe et al showed that age < 67 years, body mass index < 25 kg/m2, and hospitalization were independent risk factors for non-CVC associated UEDVT.6 The adjusted odds ratio for UEDVT was 6.2 for factor V Leiden, 5.0 for prothrombin G20210A, and 4.9 for anticoagulant protein deficiencies.3 Furthermore, hyperhomocysteinemia and oral contraceptives were not associated with UEDVT as they were with LEDVT.3 The diagnosis of UEDVT relies heavily on imaging. Contrast venography is considered the gold standard for diagnosis.5 However; ultrasonography is often used as the first choice in the clinical setting.4 Ultrasonography has excellent sensitivity and specificity on LEDVT. However, due to shadow effects from the clavicle and sternum, it is less reliable in diagnosing UEDVT. The sensitivity of ultrasonography for UEDVT is 78 to 100%, and the specificity is reported as 82 to 100%.3 Magnetic resonance imaging and spiral CT have also been used as alternatives to venography.5 The treatment of UEDVT is somewhat controversial and can be divided into three main categories: anticoagulants, thrombolysis, and surgical procedures.5 The American College of Chest Physicians (ACCP), recommends treatment with therapeutic anticoagulants and long-term treatment with vitamin K antagonists for at least 3 months for patients with UEDVT.1 More recently, a study by Malinoski et al in 2011 demonstrated that more than half of all UEDVTs were resolved before being discharged, and that anticoagulation therapy was not associated with higher rates of resolution.1 Thus, the debate on whether to administer the anticoagulation therapy still continues. Local or systemic thrombolysis have been a mainstay of therapy in the past, but has inconsistent results and high rates of complications including intracranial hemorrhage, anaphylactic shock, and death.5 Superior vena cava filters can act as a protection against PE in patients that have been unresponsive to pharmacological therapy, but is not commonly performed.5 There is also debate regarding prophylaxis against UEDVT. Joffe et al showed that only 20% of UEDVT patients received prophylaxis. Of those 20%, a quarter of them received subcutaneous unfractionated heparin (UFH).6 This is important to note, because UFH has not been shown to reduce the risk of UEDVT. Instead, low-dose warfarin or LMWH should be used for prophylaxis6. The most recent ACCP guidelines (eighth edition) from 2008 recommend no specific prophylaxis to prevent catheter-related thrombosis in cancer patients. However, routine thromboprophylaxis should be administered according to risk of venous thromboembolic event (VTE) in acute care settings.2 In the past, low morbidity and mortality rates were documented for UEDVT. However, recent studies have shown that there are significant rates of both morbidity and mortality. A study by Lee et al in 2012 reported an overall mortality rate of 9.6%, and a 1-month mortality rate of 6.4%.2 The majority of deaths occur from advanced age or underlying disease, such as end-stage cancer.5 Pulmonary emboli and
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
276
Letter to the Editor: Short Reports ment and did not suffer any adverse consequences. This case is instructive of the importance having UEDVT in the differential diagnosis of any patient with CVC, cancer, or immobility.
References 1 Malinoski DJ, Ewing T, Patel MS, et al. The natural history of upper
2
3
4 5 6
extremity deep venous thromboses in critically ill surgical and trauma patients: what is the role of anticoagulation? J Trauma 2011;71(2):316–321, discussion 321–322 Lee JA, Zierler BK, Zierler RE. The risk factors and clinical outcomes of upper extremity deep vein thrombosis. Vasc Endovascular Surg 2012;46(2):139–144 Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004;110(5):566–570 Saseedharan S, Bhargava S. Upper extremity deep vein thrombosis. Int J Crit Illn Inj Sci 2012;2(1):21–26 Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Curr Opin Pulm Med 1999;5(4):222–226 Joffe HV, Kucher N, Tapson VF, Goldhaber SZ; Deep Vein Thrombosis (DVT) FREE Steering Committee. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation 2004;110(12):1605–1611
Journal of Reconstructive Microsurgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
postthrombotic syndrome are the major complications that can follow UEDVT. Lee et al reported that 9% of UEDVT resulted in PE.2 However, other studies have reported PE rates up to 36%.4,5 Furthermore, UEDVT may give rise to loss of vascular access, superior vena cava syndrome, and postthrombotic syndrome.5,6 Postthrombotic syndrome, or chronic venous insufficiency, is seen with venous hypertension, pain, and arm swelling. UEDVT are becoming more common with the increased use of CVC and peripherally inserted central catheter lines. However, this entity is also seen in cancer patients. Our patient had two important risk factors for developing UEDVT, namely cancer and immobility. Whether RFFF harvest was a contributing factor, or unrelated event to the formation of UEDVT and the subsequent VTE, cannot be established from this report. It is possible that the operative tourniquet could have contributed to the presentation of VTE in this patient. Thus, we caution close observation in patients undergoing upper extremity surgical control with a tourniquet, regardless of tourniquet duration. However, this is the first report of VTE in association with RFFF harvest. Like most UEDVT, his was asymptomatic until PE developed on postoperative day 8. Our patient was fortunate, in that he received proper treat-
277
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
275
Upper Extremity Deep Vein Thrombosis and Pulmonary Embolus after Radial Forearm Free Flap: A Case Report and Literature Review Jon Ver Halen, MD2
Sandeep Samant, MBBS1
1 Department of Otolaryngology/Head and Neck Surgery, University of
Tennessee Health Science Center, Memphis, Tennessee 2 Department of Plastic and Reconstructive Surgery, Baptist Cancer Center/Vanderbilt Ingram Cancer Center, Memphis, Tennessee
Address for correspondence Jon Ver Halen MD, FACS, 6215 Humphreys Blvd, Ste 209, Memphis, TN 38120 (e-mail: [email protected]).
J Reconstr Microsurg 2014;30:275–278.
Background Deep vein thrombosis (DVT) and its associated complications such as pulmonary embolism (PE) are well-known causes of morbidity and mortality in the surgical intensive care unit settings. The presentation, diagnosis, and management of lower extremity DVT (LEDVT) are well documented in the literature. However, the same is not true of those that occur in the upper extremities.1 Upper extremity DVT (UEDVT) are less common than LEDVT , and usually asymptomatic until their complications arise. Risk factors for UEDVT differ from those of LEDVT, and include presence of a central venous catheter, cancer, and immobility.1,2 The first line therapy for UEDVT is systemic anticoagulation with low molecular weight heparin and long-term vitamin K antagonist therapy. Although less than in LEDVT, there is significant morbidity and mortality related to UEDVT, including PE and postthrombotic syndrome. We present a case of UEDVT that occurred in a head and neck cancer patient following relative immobility subsequent to radial forearm free flap harvest from his left arm.
Case Report Our patient is a 57-year-old Caucasian male who had undergone a left hemiglossectomy for radiation-induced sarcoma. At the time of his surgical excision, he had a radial forearm free flap (RFFF) taken from his left forearm that was used for reconstruction of his glossectomy defect. RFFF harvest was accomplished under 250 mm Hg upper arm tourniquet control for 47 minutes. Only the main radial artery pedicle and venae comitantes were used, thus excluding the cephalic vein from harvest. He also had a tracheostomy tube placed at the time of the operation. His course was complicated by a pulmonary embolism (PE) on postoperative day 8.
received September 15, 2013 accepted after revision October 6, 2013 published online January 7, 2014
The patient’s tracheostomy tube had been capped on day 5 and he had no respiratory distress. However, he had marginal oxygen saturations with occasional desaturations into the 80% range. He was started on supplemental oxygen through nasal cannula. A chest X-ray showed bibasilar atelectasis, and he was given an incentive spirometer. There were no intravenous lines of any kind placed in the left arm, and only a peripherally-inserted intravenous line on the right arm. The patient had been meeting with the physical therapy daily since his operation. However, his therapy course was difficult secondary to left arm pain. As a result of this pain, the patient was relatively immobile and had difficulty moving his left arm. In addition, a noncircumferential wound vaccumassisted closure device (VAC) at 125 mm Hg of continuous pressure and volar intrinsic-plus (Sammons Preston plaster, Lakewood, NJ) forearm splint was in place on the left forearm, which added a challenge to mobility. His respiratory status remained unchanged until the evening of day 8, when he started to complain of mild chest pain along with occasional desaturation into the 80% range on supplemental oxygen. A computed tomography (CT) pulmonary angiogram was performed, which showed pulmonary artery embolisms that involved the left main pulmonary artery and the right segmental pulmonary arteries (►Fig. 1). Ultrasonography was negative for lower extremity DCT (LEDVT), but revealed a thrombus located in the left brachial vein. The patient had been on low dose of subcutaneous heparin throughout his hospitalization for prophylaxis of DVT. He was also maintained on 81 mg of aspirin per free flap protocol. He did not have a central venous catheter (CVC) at any time during his hospitalization. After his PE was detected, he was treated initially with a therapeutic heparin drip and transitioned to low molecular weight heparin (LMWH), and
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1361845. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Joshua Wood, MD1
Letter to the Editor: Short Reports
Fig. 1 A computed tomography pulmonary angiogram was performed, which demonstrated pulmonary artery embolisms involving the left main pulmonary artery and the right segmental pulmonary arteries. Figure depicts thrombus located in the left main pulmonary artery.
enoxaparin therapy 2 days later. The patient did not have any further chest pain, respiratory distress, or complications from his pulmonary emboli. The patient had further surgery for skin graft to be placed at the RFFF donor site, so we elected to continue therapy with enoxaparin. He was discharged from the hospital 10 days later. Following his skin graft procedure, he was transitioned to warfarin therapy. Hypercoagulable workup as an outpatient was negative for any routine abnormality. Items for screening included activated protein C resistance (i.e., factor V Leiden deficiency); prothrombin G20210A mutation; deficiencies of antithrombin III, protein C, protein S; hyperhomocysteinemia; and antiphospholipid antibody syndrome.
Discussion Upper extremity DVT (UEDVT) accounts for only 1 to 10% of all DVT, and occur at the rate of 3 per 100,000 in the general population.1,3,4 However, this is thought to be an underestimate because it only reflects the symptomatic and documented UEDVT.2,4 UEDVT may occur in the following veins (in descending order of frequency): the subclavian vein, internal jugular vein, axillary vein, and the brachial vein. Oftentimes, the DVT is found in more than one segment of the veins at a time.4,5 The risk factors for UEDVTs differ from those of its counterparts in the lower extremities. Known risk factors for LEDVT such as surgery, advancing age, and obesity were not seen as risk factors for UEDVT.6 Instead, risk factors for UEDVT include cancer, history of venous thromboembolism, concomitant LEDVT, the presence of a CVC, hypercoagulable states, contraindications for anticoagulation, and immobilization for more than 3 days.1,2 The single most important factor is the presence of CVC, which accounts for 45 to 72% of all UEDVT.1,5,6 Cancer is also a strong risk factor. Most cancer Journal of Reconstructive Microsurgery
Vol. 30
No. 4/2014
patients are undergoing chemotherapy, hormone therapy, radiotherapy, surgery, have indwelling CVC and are immobile to some degree. All of these lead to greater propensity for UEDVT formation. Joffe et al showed that age < 67 years, body mass index < 25 kg/m2, and hospitalization were independent risk factors for non-CVC associated UEDVT.6 The adjusted odds ratio for UEDVT was 6.2 for factor V Leiden, 5.0 for prothrombin G20210A, and 4.9 for anticoagulant protein deficiencies.3 Furthermore, hyperhomocysteinemia and oral contraceptives were not associated with UEDVT as they were with LEDVT.3 The diagnosis of UEDVT relies heavily on imaging. Contrast venography is considered the gold standard for diagnosis.5 However; ultrasonography is often used as the first choice in the clinical setting.4 Ultrasonography has excellent sensitivity and specificity on LEDVT. However, due to shadow effects from the clavicle and sternum, it is less reliable in diagnosing UEDVT. The sensitivity of ultrasonography for UEDVT is 78 to 100%, and the specificity is reported as 82 to 100%.3 Magnetic resonance imaging and spiral CT have also been used as alternatives to venography.5 The treatment of UEDVT is somewhat controversial and can be divided into three main categories: anticoagulants, thrombolysis, and surgical procedures.5 The American College of Chest Physicians (ACCP), recommends treatment with therapeutic anticoagulants and long-term treatment with vitamin K antagonists for at least 3 months for patients with UEDVT.1 More recently, a study by Malinoski et al in 2011 demonstrated that more than half of all UEDVTs were resolved before being discharged, and that anticoagulation therapy was not associated with higher rates of resolution.1 Thus, the debate on whether to administer the anticoagulation therapy still continues. Local or systemic thrombolysis have been a mainstay of therapy in the past, but has inconsistent results and high rates of complications including intracranial hemorrhage, anaphylactic shock, and death.5 Superior vena cava filters can act as a protection against PE in patients that have been unresponsive to pharmacological therapy, but is not commonly performed.5 There is also debate regarding prophylaxis against UEDVT. Joffe et al showed that only 20% of UEDVT patients received prophylaxis. Of those 20%, a quarter of them received subcutaneous unfractionated heparin (UFH).6 This is important to note, because UFH has not been shown to reduce the risk of UEDVT. Instead, low-dose warfarin or LMWH should be used for prophylaxis6. The most recent ACCP guidelines (eighth edition) from 2008 recommend no specific prophylaxis to prevent catheter-related thrombosis in cancer patients. However, routine thromboprophylaxis should be administered according to risk of venous thromboembolic event (VTE) in acute care settings.2 In the past, low morbidity and mortality rates were documented for UEDVT. However, recent studies have shown that there are significant rates of both morbidity and mortality. A study by Lee et al in 2012 reported an overall mortality rate of 9.6%, and a 1-month mortality rate of 6.4%.2 The majority of deaths occur from advanced age or underlying disease, such as end-stage cancer.5 Pulmonary emboli and
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
276
Letter to the Editor: Short Reports ment and did not suffer any adverse consequences. This case is instructive of the importance having UEDVT in the differential diagnosis of any patient with CVC, cancer, or immobility.
References 1 Malinoski DJ, Ewing T, Patel MS, et al. The natural history of upper
2
3
4 5 6
extremity deep venous thromboses in critically ill surgical and trauma patients: what is the role of anticoagulation? J Trauma 2011;71(2):316–321, discussion 321–322 Lee JA, Zierler BK, Zierler RE. The risk factors and clinical outcomes of upper extremity deep vein thrombosis. Vasc Endovascular Surg 2012;46(2):139–144 Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004;110(5):566–570 Saseedharan S, Bhargava S. Upper extremity deep vein thrombosis. Int J Crit Illn Inj Sci 2012;2(1):21–26 Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Curr Opin Pulm Med 1999;5(4):222–226 Joffe HV, Kucher N, Tapson VF, Goldhaber SZ; Deep Vein Thrombosis (DVT) FREE Steering Committee. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation 2004;110(12):1605–1611
Journal of Reconstructive Microsurgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
postthrombotic syndrome are the major complications that can follow UEDVT. Lee et al reported that 9% of UEDVT resulted in PE.2 However, other studies have reported PE rates up to 36%.4,5 Furthermore, UEDVT may give rise to loss of vascular access, superior vena cava syndrome, and postthrombotic syndrome.5,6 Postthrombotic syndrome, or chronic venous insufficiency, is seen with venous hypertension, pain, and arm swelling. UEDVT are becoming more common with the increased use of CVC and peripherally inserted central catheter lines. However, this entity is also seen in cancer patients. Our patient had two important risk factors for developing UEDVT, namely cancer and immobility. Whether RFFF harvest was a contributing factor, or unrelated event to the formation of UEDVT and the subsequent VTE, cannot be established from this report. It is possible that the operative tourniquet could have contributed to the presentation of VTE in this patient. Thus, we caution close observation in patients undergoing upper extremity surgical control with a tourniquet, regardless of tourniquet duration. However, this is the first report of VTE in association with RFFF harvest. Like most UEDVT, his was asymptomatic until PE developed on postoperative day 8. Our patient was fortunate, in that he received proper treat-
277
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
