Clinical History
We describe a case of right superior vena cava thrombosis, studied with CT angiography, in a 64-year-old woman with known colon cancer who was admitted to our hospital because of slight swelling and
pain in her left arm.
Imaging Findings
A 64-year-old woman with known colon cancer was admitted to our hospital because of a slight swelling and pain in her left arm. Two weeks before, a central venous catheter was implanted for drug
infusion (chemotherapy). After a preliminary physical examination, a color duplex ultrasonography of the left arm was performed. The presence of a left brachiocephalic deep venous thrombosis was
suspected, based on the secondary US signs. Thereafter, the patient underwent a multislice spiral CT angiography to confirm the US suspected diagnosis and to exclude concomitant pulmonary
embolism.The CT angiography was performed after an I.V. administration of a contrast medium (90 mL, 300 mgI/mL; @ 3 mL) (1-mm collimation, a pitch of 6, a slice thickness of 1.25 mm, and a
reconstruction interval of 1 mm) either in the arterial (to evaluate pulmonary arteries) or the delayed phase (CT venography: 120 s after I.V. CM injection; to evaluate venous system), with a volume
of interest extended from the neck to the diaphragm. The results of the CT angiography showed no pulmonary embolism signs, whereas the CT venography detected partial brachiocephalic vein thrombosis
extended into the superior vena cava until the distal end of the catheter. The patient was treated with an intravenous unfractionated heparin and with oral coumadin for 2 weeks. With the complete
relief of symptoms, the patient underwent CT venography (delayed phase at 120 s after I.V. CM injection) that confirmed the complete resolution of thrombus.
Discussion
The incidence of an upper extremity deep vein thrombosis (UEDVT) is increasing, because of the widespread use of central venous catheters and pacemakers. The UEDVT may also be related to
hypercoagulability as well as low-flow states, and occasionally to effort thrombosis in young athletes with the thoracic outlet syndrome (2). The signs and the symptoms of UEDVT include ipsilateral
pain, swelling, prominent superficial collateral veins, and range-of-motion limitation, although fewer than 50% of the patients with symptoms suggesting DVT actually have it; however, UEDVT may be
completely asymptomatic and without clinical signs. The incidence of pulmonary embolism (PE) in the patients with UEDVT is reported to be between 12% and 36%, and up to 16% of the patients so
affected died. Disabling morbidity without PE, such as chronic pain, induration, edema, skin ulceration, and weakness (post-thrombotic syndrome), may occur in up to 75% of the patients. On the basis
of complication rates, an early and accurate diagnosis of UEDVT is mandatory, even if notoriously difficult (3). A venography is considered to be the gold standard in the evaluation of upper
extremities venous system, even if it is invasive, expensive, has a definite, although low, morbidity and a mortality rate; additionally, 5%–10% or more of studies were inadequate, and there
was an interobserver disagreement in up to 10% of the examinations (4). Actually, the initial test of choice for UEDVT is color duplex ultrasonography (US), for which the literature reports a
diagnostic accuracy of nearly 95% (2). However, the superior vena cava and more central portions of brachiocephalic veins cannot be routinely visualized with ultrasonography due to anatomical
reasons. This represents a limit of ultrasonography in patients with a negative US but with clinical and cardio-respiratory signs suggestive of pulmonary embolism. In a recent report (5) based on a
large population with venous thromboembolism, venography was still adopted in 36% of patients with confirmed upper-extremity thrombosis, remaining the most valuable diagnostic tool for this problem.
In patients with indeterminate or suspected US examination, CT venography could be performed to confirm or exclude the UEDVT as an alternative to venography. A multidetector-row CT venography, with
its good spatial and temporal resolution and optimized 3D resolution (2D-3D images), allows to rapidly and easily study the upper extremities venous system, by using a small amount of contrast media
and thin sections. Clot is identified as a filling defect within a deep venous structure; in acute DVT, there is often an enlargement of the vein and perivenous edema with enhancement of the venous
wall (1). The CT venography is an accurate, feasible, and fast -imaging modality for the diagnosis of UEDVT, limiting the use of conventional venography only as a prelude to endovascular treatment
(thrombolysis/thrombectomy). The combined CT angiography and CT venography (CTVPA) represents a "one-stop shopping" imaging examination for venous thromboembolism, allowing to correctly plan with the
same contrast medium injection the management and outcome of the patients with suspected pulmonary embolism and concomitant upper-extremity thrombosis.
Differential Diagnosis List
Upper-extremity deep vein thrombosis.
Final Diagnosis
Upper-extremity deep vein thrombosis.
