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0 0 l
f
Q
q 1 0 0 1 519.242 734.134 cm 0 0 m
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.276 -.025 .151 0 0 0 c
h
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f
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h
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f
Q
q 1 0 0 1 524.943 734.109 cm 0 0 m
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h
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1.076 -1.96 .314 -2.793 -.498 -2.793 c
f
Q
q 1 0 0 1 527.972 734.134 cm 0 0 m
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h
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1.174 1.884 l
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f
Q
q 1 0 0 1 532.618 731.373 cm 0 0 m
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0 0 l
f
Q
q 1 0 0 1 535.668 731.373 cm 0 0 m
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0 0 l
f
Q
q 1 0 0 1 538.313 734.089 cm 0 0 m
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-1.136 .445 l
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-.655 .445 l
.076 .445 l
0 0 l
f
Q
q 1 0 0 1 540.287 734.039 cm 0 0 m
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-1.282 -2.666 l
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-1.25 .496 l
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-.746 .095 -.422 .655 .097 .553 c
0 0 l
f
Q
q 1 0 0 1 541.293 735.056 cm 0 0 m
-.179 0 -.308 .166 -.297 .363 c
-.292 .579 -.135 .745 .043 .745 c
.216 .745 .352 .585 .341 .388 c
.33 .172 .173 0 0 0 c
h
-.4 -3.684 m
-.876 -3.684 l
-.362 -.522 l
.114 -.522 l
-.4 -3.684 l
f
Q
q 1 0 0 1 543.543 734.089 cm 0 0 m
-.73 0 l
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-1.071 -2.144 -1.017 -2.278 -.752 -2.278 c
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-.411 -2.704 l
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-1.206 0 l
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-1.677 .445 l
-1.136 .445 l
-.968 1.47 l
-.465 1.603 l
-.654 .445 l
.076 .445 l
0 0 l
f
Q
q 1 0 0 1 544.635 735.056 cm 0 0 m
-.178 0 -.308 .166 -.297 .363 c
-.292 .579 -.135 .745 .043 .745 c
.216 .745 .352 .585 .341 .388 c
.33 .172 .173 0 0 0 c
h
-.4 -3.684 m
-.876 -3.684 l
-.362 -.522 l
.114 -.522 l
-.4 -3.684 l
f
Q
q 1 0 0 1 546.61 734.109 cm 0 0 m
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-.985 -2.042 -.822 -2.303 -.417 -2.303 c
.108 -2.303 .568 -1.642 .568 -.719 c
.568 -.255 .389 0 0 0 c
h
-.498 -2.793 m
-1.174 -2.793 -1.482 -2.392 -1.482 -1.667 c
-1.482 -.407 -.801 .483 .076 .483 c
.784 .483 1.076 .013 1.076 -.655 c
1.076 -1.96 .314 -2.793 -.498 -2.793 c
f
Q
q 1 0 0 1 550.196 731.373 cm 0 0 m
-.476 0 l
-.146 2.023 l
-.065 2.519 -.14 2.736 -.384 2.736 c
-.882 2.736 -1.433 1.495 -1.558 .713 c
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-1.877 1.654 l
-1.807 2.106 -1.709 2.698 -1.639 3.162 c
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-1.455 1.915 l
-1.201 2.583 -.773 3.225 -.211 3.225 c
.287 3.225 .454 2.812 .352 2.15 c
0 0 l
f
Q
q 1 0 0 1 552.684 734.134 cm 0 0 m
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-1.114 -2.169 -1.006 -2.335 -.838 -2.335 c
-.33 -2.335 .222 -1.069 .346 -.312 c
.384 -.057 l
.276 -.025 .151 0 0 0 c
h
.427 -2.761 m
-.054 -2.761 l
-.005 -2.487 .097 -2.068 .26 -1.476 c
.249 -1.469 l
.054 -1.959 -.352 -2.825 -1.006 -2.825 c
-1.396 -2.825 -1.607 -2.532 -1.607 -1.864 c
-1.607 -.699 -1.093 .452 .081 .452 c
.389 .452 .676 .414 .925 .357 c
.638 -1.412 .541 -2.004 .427 -2.761 c
f
Q
q 1 0 0 1 554.479 731.373 cm 0 0 m
-.476 0 l
.276 4.645 l
.752 4.645 l
0 0 l
f
Q
q 1 0 0 1 558.547 733.994 cm 0 0 m
-.146 .076 -.303 .121 -.492 .121 c
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-.72 -2.17 -.492 -2.112 -.325 -2.017 c
-.357 -2.519 l
-.546 -2.602 -.795 -2.672 -1.066 -2.672 c
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-2.002 -.42 -1.423 .592 -.46 .592 c
-.238 .592 -.06 .554 .108 .496 c
0 0 l
f
Q
q 1 0 0 1 560.374 734.134 cm 0 0 m
-.801 0 -1.114 -.973 -1.114 -1.756 c
-1.114 -2.169 -1.006 -2.335 -.838 -2.335 c
-.33 -2.335 .222 -1.069 .346 -.312 c
.384 -.057 l
.276 -.025 .152 0 0 0 c
h
.427 -2.761 m
-.054 -2.761 l
-.005 -2.487 .097 -2.068 .26 -1.476 c
.249 -1.469 l
.054 -1.959 -.351 -2.825 -1.006 -2.825 c
-1.395 -2.825 -1.606 -2.532 -1.606 -1.864 c
-1.606 -.699 -1.093 .452 .081 .452 c
.39 .452 .676 .414 .925 .357 c
.638 -1.412 .541 -2.004 .427 -2.761 c
f
Q
q 1 0 0 1 563.452 734.039 cm 0 0 m
-.497 .165 -1.027 -1.075 -1.168 -1.953 c
-1.282 -2.666 l
-1.758 -2.666 l
-1.249 .496 l
-.784 .496 l
-.828 .222 -.903 -.115 -1.06 -.668 c
-1.049 -.674 l
-.746 .095 -.422 .655 .097 .553 c
0 0 l
f
Q
q 1 0 0 1 564.999 734.159 cm 0 0 m
-.427 0 -.714 -.439 -.838 -.973 c
-.005 -.935 .363 -.738 .363 -.356 c
.363 -.127 .217 0 0 0 c
h
-.898 -1.393 m
-.914 -1.489 -.925 -1.648 -.925 -1.762 c
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-.092 -2.379 .179 -2.309 .411 -2.195 c
.411 -2.653 l
.152 -2.774 -.162 -2.844 -.514 -2.844 c
-1.13 -2.844 -1.417 -2.532 -1.417 -1.819 c
-1.417 -.592 -.838 .433 .054 .433 c
.628 .433 .844 .089 .844 -.286 c
.844 -.967 .254 -1.342 -.898 -1.393 c
f
Q
EMC
/Artifact <</Type/Layout>>BDC
q
0 841.89 595.276 -841.89 re
297.66 421.02 m
W n
.059998 841.98 595.32 -841.92 re
W n
1 .89 0 0 k
q 1 0 0 1 297.525 640.486 cm 0 0 m
272.013 0 l
273.579 0 274.848 -1.269 274.848 -2.835 c
274.848 -80.761 l
274.848 -82.327 273.579 -83.596 272.013 -83.596 c
-272.013 -83.596 l
-273.579 -83.596 -274.848 -82.327 -274.848 -80.761 c
-274.848 -2.835 l
-274.848 -1.269 -273.579 0 -272.013 0 c
h
f*
Q
EMC
/P <</MCID 4>>BDC
BT
/F1 1 Tf
11 0 0 11 43.9147 612.1817 Tm
0 0 0 0 k
0 Tc
.0602 Tw
(Central vein thrombosis \(CVT\) is a serious problem for patients in whom central venous access is vital)Tj
ET
EMC
/P <</MCID 5>>BDC
BT
11 0 0 11 43.9147 596.1817 Tm
.01 Tc
.1775 Tw
[(for their nutritional support. It must be recognised and, if acute, treated as a medical emergency)74.2(.)]TJ
ET
EMC
/P <</MCID 6>>BDC
BT
11 0 0 11 43.9147 580.1817 Tm
0 Tc
0 Tw
(Impending loss of venous access is a reason to be considered for a small bowel transplant.  )Tj
ET
EMC
/P <</MCID 7>>BDC
BT
/F2 1 Tf
12 0 0 12 22.6771 538.6534 Tm
1 .89 0 0 k
(Key points)Tj
ET
EMC
/P <</MCID 8>>BDC
BT
/F1 1 Tf
8 0 0 8 22.6771 520.984 Tm
0 0 0 .8 k
-.015 Tc
(1.)Tj
ET
EMC
/P <</MCID 9>>BDC
BT
8 0 0 8 34.0157 520.984 Tm
-.02 Tc
[(T)37.1(reatment of CVT)18.1( depends on the chronicity of the condition, the underlying)]TJ
ET
EMC
/P <</MCID 10>>BDC
BT
8 0 0 8 34.0157 508.984 Tm
0 Tc
(cause and the clinical presentation.)Tj
ET
EMC
/P <</MCID 11>>BDC
BT
8 0 0 8 22.6771 496.984 Tm
(2.)Tj
ET
EMC
/P <</MCID 12>>BDC
BT
8 0 0 8 34.0157 496.984 Tm
[(Acute CVT)18.1( is a medical emergency requiring an urgent Doppler )]TJ
ET
EMC
/P <</MCID 13>>BDC
BT
8 0 0 8 34.0157 484.984 Tm
[(ultrasound and/or CT)18.1( venogram.)]TJ
ET
EMC
/P <</MCID 14>>BDC
BT
8 0 0 8 22.6771 472.984 Tm
-.01 Tc
(3.)Tj
ET
EMC
/P <</MCID 15>>BDC
BT
8 0 0 8 34.0157 472.984 Tm
[(For acute CVT)110.9(, thrombolysis can be given via a separate catheter directly)]TJ
ET
EMC
/P <</MCID 16>>BDC
BT
8 0 0 8 34.0157 460.984 Tm
0 Tc
[(into the clot \(catheter-directed thrombolysis\). )18.1(This should be performed )]TJ
ET
EMC
/P <</MCID 17>>BDC
BT
8 0 0 8 34.0157 448.984 Tm
(by a specialist vascular interventional radiologist with the appropriate )Tj
ET
EMC
/P <</MCID 18>>BDC
BT
8 0 0 8 34.0157 436.984 Tm
[(expertise. )18.1(T)37.1(reatment within 14 days may prevent later venous stenosis/ )]TJ
ET
EMC
/P <</MCID 19>>BDC
BT
8 0 0 8 34.0157 424.984 Tm
(occlusion.)Tj
ET
EMC
/P <</MCID 20>>BDC
BT
8 0 0 8 22.6771 412.984 Tm
(4.)Tj
ET
EMC
/P <</MCID 21>>BDC
BT
8 0 0 8 34.0157 412.984 Tm
(Chronic venous occlusion may be treated with venoplasty with or without)Tj
ET
EMC
/P <</MCID 22>>BDC
BT
8 0 0 8 34.0157 400.984 Tm
(placement of a venous stent.)Tj
ET
EMC
/P <</MCID 23>>BDC
BT
8 0 0 8 22.6771 388.984 Tm
(5.)Tj
ET
EMC
/P <</MCID 24>>BDC
BT
8 0 0 8 34.0157 388.984 Tm
(Long-term anticoagulation must be considered, with any decision to )Tj
ET
EMC
/P <</MCID 25>>BDC
BT
8 0 0 8 34.0157 376.984 Tm
(cease determined on a case-by-case basis involving discussions with )Tj
ET
EMC
/P <</MCID 26>>BDC
BT
8 0 0 8 34.0157 364.984 Tm
(an expert in intestinal failure/parenteral support. )Tj
ET
EMC
/P <</MCID 27>>BDC
BT
8 0 0 8 22.6771 352.984 Tm
(6.)Tj
ET
EMC
/P <</MCID 28>>BDC
BT
8 0 0 8 34.0157 352.984 Tm
[(The cause of the thrombosis should be investigated. )55.2(A)55.2( catheter tip in the )]TJ
ET
EMC
/P <</MCID 29>>BDC
BT
8 0 0 8 34.0157 340.984 Tm
(upper SVC or brachiocephalic veins is the most common association.)Tj
ET
EMC
/P <</MCID 30>>BDC
BT
8 0 0 8 22.6771 328.984 Tm
(7.)Tj
ET
EMC
/P <</MCID 31>>BDC
BT
8 0 0 8 34.0157 328.984 Tm
(When 2 of the 4 major supra-diaphragmatic veins have been lost there )Tj
ET
EMC
/P <</MCID 32>>BDC
BT
8 0 0 8 34.0157 316.984 Tm
(should be consideration for a small bowel transplant.)Tj
ET
EMC
/P <</MCID 33>>BDC
BT
/F2 1 Tf
12 0 0 12 22.6771 295.484 Tm
1 .89 0 0 k
(Explanations  )Tj
ET
EMC
/P <</MCID 34>>BDC
BT
8 0 0 8 22.6771 277.8147 Tm
0 0 0 .8 k
(A.)Tj
ET
EMC
/P <</MCID 35>>BDC
BT
/F1 1 Tf
8 0 0 8 34.0157 277.8147 Tm
[(CVT)18.1( occurs at a frequency of 0.06-0.12/1000 catheter-days. )]TJ
ET
EMC
/P <</MCID 36>>BDC
BT
8 0 0 8 34.0157 265.8147 Tm
(Its pathogenesis is multifactorial and includes: a\) vessel injury )Tj
ET
EMC
/P <</MCID 37>>BDC
BT
8 0 0 8 34.0157 253.8147 Tm
(\(+/- subsequent venous stasis\) during/following catheter insertion; b\) )Tj
ET
EMC
/P <</MCID 38>>BDC
BT
8 0 0 8 34.0157 241.8147 Tm
(damage to the endothelium caused by the infusion of parenteral nutrition)Tj
ET
EMC
/P <</MCID 39>>BDC
BT
8 0 0 8 34.0157 229.8147 Tm
(that has a very high osmolality; c\) mechanical rubbing of the catheter )Tj
ET
EMC
/P <</MCID 40>>BDC
BT
8 0 0 8 34.0157 217.8147 Tm
(against the vessel wall. Patients with a superior vena cava \(SVC\) throm)Tj
ET
EMC
/P <</MCID 41>>BDC
BT
8 0 0 8 34.0157 205.8147 Tm
(bosis usually present complaining of a sensation of a swollen )Tj
ET
EMC
/P <</MCID 42>>BDC
BT
8 0 0 8 34.0157 193.8147 Tm
(erythematous head, a positional headache and swollen arms. )Tj
ET
EMC
/P <</MCID 43>>BDC
BT
8 0 0 8 34.0157 181.8147 Tm
(On examination distended non-pulsatile jugular veins may be noted and,)Tj
ET
EMC
/P <</MCID 44>>BDC
BT
8 0 0 8 34.0157 169.8147 Tm
(if chronic, there may be venous collaterals over the upper chest wall.)Tj
ET
EMC
/P <</MCID 45>>BDC
BT
8 0 0 8 34.0157 157.8148 Tm
[(A)55.2( brachiocephalic thrombosis may present with unilateral swelling with )]TJ
ET
EMC
/P <</MCID 46>>BDC
BT
8 0 0 8 34.0157 145.8148 Tm
(or without facial symptoms. If collaterals have already formed then )Tj
ET
EMC
/P <</MCID 47>>BDC
BT
8 0 0 8 34.0157 133.8148 Tm
(symptoms may be minimal or even absent.)Tj
ET
EMC
/P <</MCID 48>>BDC
BT
/F2 1 Tf
8 0 0 8 303.5263 541.5655 Tm
(B.)Tj
ET
EMC
/P <</MCID 49>>BDC
BT
/F1 1 Tf
8 0 0 8 314.865 541.5655 Tm
(Home parenteral support requires long-term and safe venous access. )Tj
ET
EMC
/P <</MCID 50>>BDC
BT
8 0 0 8 314.865 529.3155 Tm
(This is usually performed with a tunnelled catheter with its tip positioned )Tj
ET
EMC
/P <</MCID 51>>BDC
BT
8 0 0 8 314.865 517.0655 Tm
[(at the right atrial/caval junction. )55.2(A)55.2( loss of venous access is catastrophic )]TJ
ET
EMC
/P <</MCID 52>>BDC
BT
8 0 0 8 314.865 504.8155 Tm
(for these patients and, therefore, if suspected then the patient should )Tj
ET
EMC
/P <</MCID 53>>BDC
BT
8 0 0 8 314.865 492.5655 Tm
(undergo urgent radiological investigation and treatment.)Tj
ET
EMC
/P <</MCID 54>>BDC
BT
/F2 1 Tf
8 0 0 8 303.5263 474.6462 Tm
(C.)Tj
ET
EMC
/P <</MCID 55>>BDC
BT
/F1 1 Tf
8 0 0 8 314.865 474.6462 Tm
[(In acute cases of CVT)110.9(, a thrombolysis cannula \(with many side holes\) )]TJ
ET
EMC
/P <</MCID 56>>BDC
BT
8 0 0 8 314.865 462.3962 Tm
-.02 Tc
(may be inserted under radiological guidance into the clot and a thrombolytic)Tj
ET
EMC
/P <</MCID 57>>BDC
BT
8 0 0 8 314.865 450.1462 Tm
0 Tc
[(agent continuously infused \(e.g. tP)74.2(A\), with repeat venography at 24 )]TJ
ET
EMC
/P <</MCID 58>>BDC
BT
8 0 0 8 314.865 437.8962 Tm
(hours and every 1-2 days till the clot has lysed. 24 hours after the clot )Tj
ET
EMC
/P <</MCID 59>>BDC
BT
8 0 0 8 314.865 425.6462 Tm
(has been lysed the catheter may be removed and a new one inserted )Tj
ET
EMC
/P <</MCID 60>>BDC
BT
8 0 0 8 314.865 413.3962 Tm
(on the other side \(usually when anticoagulation has been temporarily )Tj
ET
EMC
/P <</MCID 61>>BDC
BT
8 0 0 8 314.865 401.1462 Tm
(stopped\). Unfractionated heparin is used initially as a bridge until full )Tj
ET
EMC
/P <</MCID 62>>BDC
BT
8 0 0 8 314.865 388.8962 Tm
(oral anticoagulation, usually with warfarin, is achieved. Early treatment )Tj
ET
EMC
/P <</MCID 63>>BDC
BT
8 0 0 8 314.865 376.6462 Tm
[(should, in most cases of acute thrombosis, restore venous patency)74.2(. )]TJ
ET
EMC
/P <</MCID 64>>BDC
BT
8 0 0 8 314.865 364.3962 Tm
[(This must be confirmed with repeated venography)74.2(.)]TJ
ET
EMC
/P <</MCID 65>>BDC
BT
/F2 1 Tf
8 0 0 8 303.5263 346.4768 Tm
(D.)Tj
ET
EMC
/P <</MCID 66>>BDC
BT
/F1 1 Tf
8 0 0 8 314.865 346.4768 Tm
(For patients with CVT/stenosis, it may be possible to balloon dilate )Tj
ET
EMC
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