The T, CVC-induced, recognizes several causes. The vein can be damaged by hyperosmolar fluid or at the time of insertion of the catheter and stasis can be induced by its presence. Moreover the repeated trauma of the tip of catheter, induced by cardiac activity, can injure the endothelium surface [4
]. The hypercoagulable state as that of cancer, myeloproliferative diseases [5
], trauma, or surgery (as in the described case) must be considered a predisposing factor.
All these factors are the Virchow's triad
. Furthermore the risk of thrombosis is related to the permanence of CVC and is higher in elderly and systemically ill patients [6
Not rarely the SVC T is asymptomatic; symptoms, when present, are usually upper limbs edema and a slight shoulder and neck pain [7
]. The complete vein occlusion is associated with the classic SVC syndrome
: arm and facial swelling, stridor, blurred vision, dyspnea, dizziness, positional headache, retroorbital pain, dysphagia, and chest pain [6
]. The chronic and inveterate obstructions can be associated with the signs of increased cervical venous pressure.
Such complications are normally observed while the catheter is in place. In our patient the thrombosis was demonstrated after the removal of the CVC; we found only one similar clinical case reported [8
]. In addition, the T did not induce complete occlusion of the SVC, (as is clearly shown in ) and this explains why the patient was essentially asymptomatic.
Since the clinical presentation is often silent or nonspecific, the diagnosis can be incidental by duplex ultrasound, echocardiography, CT, or MRI. In our patient the echocardiography was fundamental for the diagnosis of cardiac mass. For the differential diagnosis, the myxoma, though pedunculated and mobile, is usually left atrial sided rather than right sided.
The proof of a thrombotic occlusion of the veins by Doppler ultrasonography of the upper extremities increases the diagnostic suspect finally confirmed by CT or MRI.
These techniques have a high diagnostic accuracy with excellent anatomic definition of the whole T and its relationship with adjacent structures. Moreover they show the collateral pathways. However, the use of ionizing radiation for the CT and of contrast agents with the risk of nephrotoxicity makes them unsuitable in some patients [4
Oral anticoagulation is the first choice therapy. Surgical thrombectomy and thrombolysis are indicated in cases of massive T and hemodynamic instability and PE [3
]. Balloon angioplasty and stent placement can be useful in the case of chronic obstructions and SVC syndrome [6
For the elderly, the poor general condition, the incomplete vessel thrombosis, the absence of PE, but, on the other hand, the risk of clot migration after stalk lysis, the patient was treated with warfarin at target INR 2-3, with good results.
The CVC-induced T is a challenge. The clinical presentation, often silent, may lead to underestimation. Only a high index of suspicion may allow early detection, before the onset of complications.
The patient's general condition (cancer, multiple trauma, major surgery, systemic diseases, cachexia, and dialysis), difficult insertion of CVC, particularly if followed by thrombocytopenia, [3
] should prompt the suspicion of T CVC induced.
The optimal management and care of CVC must provide a routine duplex ultrasound and echocardiogram of the upper limbs veins, of the SVC, and of the right heart's chambers. This will avoid complications even lethal.