Deep Venous Thrombosis (DVT), Upper Extremity

• • Axillary-subclavian thrombosis: 3 etiologies

  • 1. Paget-Schroetter syndrome: Also called "effort thrombosis"

    -Results from intermittent obstruction of vein during repetitive arm/shoulder movements

    -Subclavian vein compressed between first rib, anterior scalene muscle, and clavicle

    2. Primary subclavian venous thrombosis occurs in patients with hypercoagulable states

    3. Secondary subclavian venous thrombosis results from venous injury (central lines, external trauma, pacemaker wires)

Epidemiology

• • Thrombosis of axillary/subclavian vein < 5% of DVT; 12% result in PE

  • Paget-Schroetter affects more men than women (4:1); 56% are hypercoaguable

  • -Occurs in healthy young athletes and persons who perform manual labor

Symptoms and Signs

Paget-Schroetter

• • Repetitive arm activity and exercise

  • Significant superficial venous distention in arm/shoulder

  • Aching pain

  • Cyanosis of chest wall, axilla, shoulder, and arm

  • Other symptoms of thoracic outlet syndrome may be present (see Thoracic Outlet Syndrome)

Subclavian Venous Thrombosis

• • Edematous, cyanotic arm, hand

Imaging Findings

• • Duplex US of upper extremity

  • Venography + thrombolysis considered if duplex US is abnormal (positional venography with arm abducted 120 degrees)

  • Chest film: Exclude cervical rib

• • Evaluate for other evidence of hypercoagulability

• • Duplex US

  • Possible venogram

• • Remove indwelling central lines/ pacemakers

  • Elevate arm, hydrate with IV fluid

  • Thrombolysis

  • -If vein stenotic, perform angioplasty on vein segment

  • Vein compression with large collaterals suggests venous thoracic outlet syndrome and necessitates early operation

  • Surgical thoracic outlet decompression

  • -Resect anterior scalene muscle

    -First rib resection

    -Venoplasty

Surgery

Indications

• • Venous thoracic outlet syndrome

Complications

• • Without surgery, venous thoracic outlet syndrome carries a 35-65% risk of rethrombosis

Prognosis

• • Excellent if treated early

  • If thrombosis exists > 3 mos, it does not respond to therapy and may cause significant long-term disability

• • Urschel HC et al. Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg. 2000;69:1663.