Clinical Presentation
A 24-year-old African American male with a history of active IVDA, hepatitis C and right upper extremity DVT non-compliant with eliquis brought in by police for atraumatic bilateral upper extremity pain x1 week.
On exam, the patient had erythema, induration and mild tenderness to the bilateral forearms without crepitus. The remainder of the patient’s exam and vitals were unremarkable.
Differential Diagnosis
· Cellulitis
· Abscess
· Arterial embolism
· DVT
· Superficial thrombophlebitis (superficial venous thrombosis)
· Necrotizing soft tissue infection
POCUS
What is the diagnosis?
Diagnosis
The POCUS images demonstrate a superficial venous thrombosis >5cm in length.
Disposition
The patient was admitted to the hospital for IV vancomycin and to restart his eliquis.
Discussion
Presentation (Signs & symptoms)
o Focal pain
o Erythema
o Varicosity
Epidemiology
o Lower extremities much more commonly affected than upper extremity
o 2/3 involve the saphenous vein
Etiology/Risk Factors
o Chronic venous insufficiency
o Hypercoagulable
o Pregnancy
o Estrogen therapy
o Sclerotherapy
o Obesity
o Malignancy
o Travel
o Male
o Varicose veins
o PICC or PIV
Diagnosis
Ultrasound
o Diagnostic imaging modality of choice
Ø Linear (vascular)
o Benefits: rapid, accurate, no contrast/radiation
o Findings
Ø Non-compressible superficial vein
Ø Internal hyperechoic artifact
o High risk findings (that warrant anticoagulation)
Ø >5cm in length
Ø within 2cm of a deep vein
o 4% have concurrent PE
Ø Workup as indicated
o 23% have concurrent DVT
Ø Perform DVT POCUS on all patients with SVT
D-dimer: no role; poor sensitivity
Treatment (2009 ACCP Guidelines)
o >5cm in length
o Daily prophylactic dose of fondaparinux 2.5mg >> LMWH
o Duration: 45 days
Complications
o PE (0.5% of cases)
o DVT (2.6% of cases)
o Extension of SVT (3%)
o Recurrence of SVT (2%)
References
Kearon, C et al. Antithrombotic Therapy for VTE Disease. Chest. 2009;141(2):e419S- e496S.
Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Int Med. 2010;152(4):218-224.
Liem TK, Yanit KE, Moseley SE, et al. Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis. J Vasc Surg. 2012;55(3):761-767.
Sartori M, Migliaccio L, Favaretto E, et al. D-dimer for the diagnosis of upper extremity deep and superficial venous thrombosis. Thrombosis Research. 2015;135(4):673-678.