Management of Upper Extremity Deep Venous Thrombosis in a Hospice Patient

Introduction

Deep venous thrombosis (DVT) is a common occurrence in patients with cancer and confers a poor prognosis compared to patients of similar cancer stage without DVT. ¹ Managing DVTs is complex, especially in a palliative care setting. ¹ Standard medical therapy with anticoagulation is typically very effective at preventing thrombus progression and pulmonary embolism. However, the anticoagulation does not directly promote thrombus dissolution and consequently can result in recurrence and further complications. ² Despite the benefits of rapid reduction of clot burden with direct thrombolytic, often the greater potential risks, including bleeding, longer hospital stay, and higher medical cost, has limited the acceptance and use of endovascular DVT therapy in patients with cancer. ² This case is intended to shed light on palliative care patients with special implications of diagnosis, treatment, and prevention of DVT due to the balance of benefit of quality of life and the risk of treatment and natural progression of the cancer.

Case Presentation

A 43-year-old Caucasian woman with a history of metastatic breast cancer presented to the hospital with the sudden onset of left arm swelling and pain. The patient also had a month-long history of left neck pain. She was diagnosed with acute DVT in the left upper extremity (LUE). Acute occlusive deep venous thrombosis was identified in the left internal jugular, subclavian, axillary, and brachial veins (Fig. 1). Superficial venous thrombosis was also observed in the basilic vein. At that time, the patient was noted to have a central catheter located in the right chest. She denied any history of recent trauma, repeated extremity usage, or history of prior DVT. Her past medical history included morbid obesity as well as left breast carcinoma status postmastectomy, axillary lymph node dissection, and chemoradiation. She had been taking tamoxifen for estrogen-sensitive carcinoma until metastatic progression with lung and lymph node involvement was diagnosed 2 months ago. Her past surgical history included bilateral laparoscopic hysterectomy with salpingo oophorectomy. There was no history of illicit drug or alcohol use. The patient was treated with the standard anticoagulation therapy for the DVT, i.e., Coumadin^® (Bristol-Myers Squibb, New York, NY) with a Lovenox^® (Sanofi, Bridgewater, NJ) bridge and pain medications.

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FIG. 1.

Angiogram showing acute occlusive deep venous thrombosis identified in the left subclavian, axillary, and brachial veins.

Ten days later, the patient returned to the emergency department due to increased erythema, persistent pain, and edema. On examination, there was edema extending from the digits to left axilla of the LUE, along with discoloration. Arterial pulses were intact bilaterally. No edema or vascular abnormalities were observed in other extremities. The repeat ultrasound indicated persistent clots with no improvement over a 10-day treatment course of systematic anticoagulation therapy. The vascular surgery department was consulted to render an opinion on this case.

After examination of the patient and discussion of treatment options, vascular surgery decided to pursue a course of treatment aimed at reducing the patient's clot burden for symptomatic relief. We proceeded to the angiographic suite to perform an angiogram, which confirmed venous occlusion. We were able to pass a wire through the clot easily, which in turn allowed us to infuse tissue plasminogen activator (tPA) throughout and perform a mechanical thrombectomy with the AngioJet^® (Medrad Inc., Warrendale, PA). After several runs, there was still a significant clot burden, and the decision was made to perform catheter-directed thrombolysis overnight. An EKOS catheter (EKOS Corporation, Bothell, WA) was placed and tPA was infused at a rate of 1 mg/hr overnight. The patient returned to the angiographic suite the following day. The subsequent angiogram showed good resolution of a majority of the clot (Fig. 2). The AngioJet thrombectomy was repeated with good result. A significant stenosis of the subclavian vein was apparent after clot dissolution that was suggestive of venous thoracic outlet syndrome. Angioplasty with a 12-mm Atlas^® high-pressure balloon (C.R. Bard, Inc., Murray Hill, NJ) was performed, followed by a 14-mm Atlas balloon. There was still a residual stenosis after angioplasty but the vein was open. Given the patient's overall prognosis and limited life expectancy, we made the decision to perform angioplasty on the lesion only and not pursue aggressive work-up or treatment. The final angiogram demonstrated unobstructed flow from the LUE to the central venous system. The patient tolerated the procedure well without complications and was discharged postoperative day 2 with decreased pain and edema in LUE. The patient remained on oral anticoagulation medications (acetylsalicylic acid [ASA], 81 mg; warfarin, 5 mg). During her hospital course, she was observed clinically for pain level and her use of pain medicines and monitored for improvement of the swollen limb. The patient remained pain-free in her LUE prior to passing away several weeks later in the hospice care.

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FIG. 2.

Angiogram post-AngioJet^® (Medrad Inc., Warrendale, PA)treatment showing patency of the left subclavian, axillary, and brachial veins.

Discussion

The patient in this case had thrombosis involving the left internal jugular, subclavian, axillary, brachial, and basilic veins. Even though UEDVT is uncommon, it should not be underestimated because it has similar complications to leg thrombosis and often occurs in young people, as this patient was 43 years old. ³ Moreover, patients with cancer with distant metastases have a considerably higher chance of occurrence than those with localized disease. ⁴ The risk factors for our patient included both metastatic breast cancer and a central catheter placed in the right chest, making the patient at higher risk for UEDVT. The anticoagulation therapy is recommended by CHEST guidelines for such patients, however, DVT management in palliative care patients represents a conflict between the principles of beneficence and nonmaleficence.^5,6

Another approach to managing DVT in patients with or without cancer is pharmacomechanical throbectomy. Previous studies have demonstrated the safety and efficacy of this method.^7,8 Pharmacomechanical thrombolysis is defined as catheter-directed thrombolytic (CDT) therapy combined with a mechanical catheter intervention, like the AngioJet system in this case. In a small study using the AngioJet in combination with thrombolytics, nearly 80% experienced greater than 90% thrombolysis and recurrence-free rates at 4-month follow-up. ⁸ In our case, this was a relatively young female with terminal metastatic breast cancer. The benefits of treatment are the reduction of symptoms, preventions of pulmonary hypertension, and reduced mortality, but must be weighed against the goals of care. ⁹ In our case the patient did not show improvements with anticoagulation therapy and was suffering from pain and symptoms. Thus, pharmacomechanical thrombolysis was used to relieve the patient from symptoms and improve the quality of life. Quality of life evaluation in the patient in this case was subjective. Prior to the patient's treatment she had endured weeks of arm swelling and pain and failed initial medical management. When pharmacomechanical thrombolysis failed in this case, an EKOS catheter was placed and tPA was infused overnight. Ultrasound-assisted thrombolysis with the EkoSonic Endovascular System (EKOS Corporation, Bothell, WA) is another catheter intervention technique that uses ultrasound to increase the permeability of the CDT and the breakup of fibrin network. ⁶ Compared with CDT, both pharmacomechanical thrombolysis and ultrasound-assisted thrombolysis reduces thrombolytic infusion time, length of hospital stay, and costs. ¹⁰

The concerns of complications associated with thrombolysis are valid. Complications include pulmonary embolism, recurrence, post-thrombotic syndrome of the arm, and death. ¹¹ Aggressive treatment of UEDVT has the potential to preserve quality of life and reduce cost and future complications in comparison to anticoagulation therapy and could be considered as the treatment of choice in selected palliative medicine patients. Some experts see a shift of paradigm in medical prophylaxes in palliative medicine in that the goal of palliative medicine is improvement of quality of life rather than preventing fatal complications from the underlying disease. ¹² In a qualitative in-depth interview study of 45 doctors from the United Kingdom, traditional hospices did not consider, actively investigate, or treat DVTs, keeping with the ethos that dying patients should have the least intervention possible. ⁵ It is difficult to say how much quality of life versus complication benefit is gained through direct thrombolysis in palliative medicine patients and a one-size-fits-all approach is inappropriate for palliative patients, as the patient context and shifting continuum of care plays into the complex benefit and burden of giving treatment for end-of-life patients. ⁵ It is generally accepted by all expert physicians that primary and secondary prophylaxes for DVT be withdrawn in a patient who is in the phase of dying from a malignant disease. ¹² Implementation of a specific prophylactic protocol for those with malignancy is necessary to decrease morbidity and mortality. ¹³ In this case once the patient's DVT was surgically managed, the patient experienced a significant decrease in pain and arm edema with a corresponding increase in hand function. Also, her overall hospital stay was shortened and she was able to return home in a timely manner. For the remainder of her life, she had no additional issues with arm swelling and pain.

In summary, UEDVT is relatively rare and so the knowledge about the risk factors and management of the problem is limited. Our case shows that a multidisciplinary approach involving many different specialties and treatment modalities is useful to bring successful treatment in palliative medicine patients with UEDVT.