Upper Extremity Deep Vein Thrombosis (DVT)

Physician

Daniel Scotti, MD
Interventional Radiologist
John F. Kennedy Hospital
Cherry Hill, NJ

Background

An 80-year old male patient presented to the emergency room with a swollen left arm. The patient’s past history included the placement of a pacemaker and defibrillator. Initial ultrasound findings were consistent with an incomplete occlusion of the left subclavian vein with involvement to the elbow. The patient was treated with heparin over a period of 9 days without resolution of the clot.

Procedure

The patient was placed in the supine position with the left arm extended, and access was made with a micro access set at the antecubital fossa. A 0.035” guidewire and catheter were placed into the basilic vein and a venogram was performed. The venogram demonstrated clot within the basilic and subclavian veins extending to the superior vena cava. An 8Fr introducer sheath was inserted. There was a tight stenosis that was associated with fibrotic pacemaker leads within the subclavian vein. This stenosis was pre-dilated using a high pressure angioplasty balloon.

A 80cm Trellis® Peripheral Infusion System with a 15cm treatment segment was placed distal to the stenosis and 5mgs of t-PA were infused over a 10-minute period. The Trellis catheter was repositioned within the basilic-vein and another 5mgs of t-PA were infused over 10 minutes. The catheter was removed and a venogram was performed. The venogram demonstrated 85% clearance of the clot with some residual clot within the subclavian vein beyond the pacemaker lead insertion site from the arm. The Trellis catheter was re-inserted into the arm and activated for 10 minutes without lytic. The Trellis catheter was removed and a venogram was performed. The venogram showed near complete patency of the left basilic and subclavian veins to the superior vena cava. The junction of the superior vena cava and suclavian vein was angioplastied with a 14mm dilatation balloon resulting in a 99% patency rate in the left arm. The patient experienced rapid relief of pain and swelling before leaving the procedure room.

Conclusion

Patency of the left subclavian vein and left basilic vein was restored in a single setting, with no ICU stay required. This case report demonstrates that isolated pharmacomechanical thrombolysis with the Trellis catheter in upper extremity DVT can deliver a safe, successful result. Symptomatic relief for the patient can be achieved even in the presence of a stenosis caused by chronic pacemaker leads.