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Cardiovascular System (CVS) ORGAN SYSTEMS

Axillary-subclavian venous thrombosis (ASVT)

Venous thromboembolism (VTE) in the axillary-subclavian vein.

Venous thromboembolism (VTE) in the axillary-subclavian vein.

History:

In 1875 Paget, and later in 1884 von Schroetter, described thrombosis of the axillary vein and Hughes, in a major review of reported cases, introduced the eponym Paget-Schroetter syndrome. Thrombosis of the axillary or subclavian vein in otherwise healthy people may be related to injury or effort but may also be spontaneous. The presence of thoracic outlet syndrome favors the development of effort-related venous thrombosis but clearly not all patients who have Paget-Schroetter syndrome have an associated thoracic outlet syndrome. The importance of thoracic outlet compression in producing axillary-subclavian venous occlusion is emphasized by data of Dunant, suggesting that up to 80% of the patients who manifest venous thrombosis had previous symptoms of intermittent venous compression. The overall incidence of venous thrombosis in the upper extremities with thoracic outlet syndrome is still only about 3.5%.

The widespread use of subclavian catheters has increased the incidence and changed the spectrum of these problems. According to Brismar, Hardstedt, and Jacobson, the length of time the catheter is in place rather than the type of catheter itself influences the risk for thrombosis. The risk from pacemaker electrodes appears to be quite low, with manifest upper extremity venous thrombosis developing in only 0.18% of our patients who underwent pacemaker implantation.


Aetiology

Primary ASVT (rare):

Patients with primary effort induced SCVT can present as typically healthy, teenage to 40 years old, males more often than females. History may reveal recent strenuous or repetitive movements of the extremity, whereas idiopathic SCVT will not have any strenuous activity history.
  • Paget-Schroetter syndrome: Unexpected thrombosis occurring after strenuous or repetitive use of the upper extremity on the affected side.
  • Idiopathic (frequently associated with undiagnosed malignancy)

Secondary ASVT: Associated with catheters or lines in the vein.

A patient’s complaints and findings in secondary SCVT are similar, but the presence of a catheter or device lead or history of trauma will be present.
  • Long term feeds
  • Prone position in surgery
  • Antithrombin III deficiency
  • Factor V Leiden mutation
  • Protein C deficiency
  • Protein S deficiency
  • Lung cancer malignancy (rare) – more common with Pancoast tumor

Clinical features

The severity of symptoms depends on the degree of venous obstruction. Early in the disease process, patients will complain of mild discomfort. As the process evolves, more prominent signs and symptoms will appear.

  • Upper extremity or neck discomfort or pain described as a “feeling of vague fullness”
  • Swelling in affected area.
Clinical presentation of subclavian vein (SCV) effort thrombosis. Photographs depicting an otherwise healthy active young woman who had experienced the recent onset of right upper extremity swelling and cyanotic discoloration, extending from the shoulder to the hand, due to SCV effort thrombosis. | Thompson R. W. (2012). Comprehensive management of subclavian vein effort thrombosis. Seminars in interventional radiology, 29(1), 44–51. https://doi.org/10.1055/s-0032-1302451

Physical examination:

  • Supraclavicular fullness
  • Changes of color of extremity
  • Urschel’s sign: Dilation of collateral veins in anterior chest wall

Diagnosis

Ultrasonography (USG):

Other imaging modalities:

CT, MRI, venography

Differential diagnosis:

  • Superior vena cava syndrome
  • Lymphatic obstruction
  • Cellulitis
  • Thoracic outlet obstruction
  • Pancoast tumor
  • Necrotizing fasciitis
  • Superficial thrombophlebitis

Management

ASVT has high rates of acute mortality and long term disability without proper and timely treatment. Early diagnosis and treatment are essential in preventing fatal acute complications, such as pulmonary embolism and long term morbidity related to venous inflow restriction.

Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment is generally done for such cases.

Nonsurgical management:

There is still a significant risk of recurrent thrombosis following thrombolysis and anticoagulation alone, with estimates ranging from 50-70%
  • Chronic anticoagulation: Catheter-based thrombolytic therapy
  • Intermittent arm elevation
  • Long-term restrictions in arm activity
  • Compression sleeves
Initial management of subclavian vein (SCV) effort thrombosis. Initial interventional management of a young man with right-sided SCV effort thrombosis. (A) Initial venogram confirming axillary-subclavian vein occlusion, with venous obstruction extending to the lateral chest wall. Very few collaterals are noted, compatible with acute obstruction. (B) Partial resolution of thrombus following catheter-directed thrombolytic therapy, clearing much of the axillary vein. (C) Restoration of axillary-subclavian vein patency with further thrombolytic therapy, revealing a residual high-grade stenosis in the SCV at the level of the first rib (arrow). (D) Inflation of an angioplasty balloon across the area of SCV stenosis, demonstrating the focal nature of the lesion as evidenced by effacement of the midportion of the balloon (arrow). (E) Successful inflation of the angioplasty balloon across the area of SCV stenosis. (F) Completion venogram demonstrating improved patency of the SCV with an area of persistent venous stenosis at the first rib (arrows). | Thompson R. W. (2012). Comprehensive management of subclavian vein effort thrombosis. Seminars in interventional radiology, 29(1), 44–51. https://doi.org/10.1055/s-0032-1302451

Surgical management:

Surgical treatment should be considered in almost all patients with venous TOS and SCV effort thrombosis as the most definitive management approach.
  • Transaxillary thoracic outlet decompression: Partial resection of the first rib and division of its scalene muscle attachments
  • Paraclavicular thoracic outlet decompression: Combines the advantages of the supraclavicular exposure used for neurogenic and arterial forms of TOS with an infraclavicular incision that permits complete resection of the medial first rib, as well as wide exposure of the SCV to permit vascular reconstruction.
Paraclavicular approach for reoperative treatment of venous thoracic outlet syndrome. Images from an active young man who had developed right-sided subclavian vein (SCV) effort thrombosis and was treated by thrombolysis and first rib resection. Over the following year he continued to experience exertional right upper extremity swelling and pain, despite several attempts at SCV balloon angioplasty. (A) Maximal intensity projection coronal (MIP) images from a contrast-enhanced computed tomography study demonstrating a persistent focal stenosis in the proximal right SCV during arm elevation, located adjacent to a small remnant of the anterior first rib (arrow). (B) Axial MIP images demonstrating expanded collateral venous pathways passing through the thoracic outlet adjacent to a remnant of the posterior first rib (arrow). (C) Operative specimens of the anterior and posterior first rib remnants removed during paraclavicular decompression, superimposed on the plain chest radiograph (arrows). (D) Intraoperative contrast venogram obtained following first rib resection and external venolysis, demonstrating a widely patent SCV with minimal filling of collateral venous pathways. | Thompson R. W. (2012). Comprehensive management of subclavian vein effort thrombosis. Seminars in interventional radiology, 29(1), 44–51. https://doi.org/10.1055/s-0032-1302451

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