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This case report describes thrombolysis for axillosubclavian vein thrombosis, and discusses causes and current opinion on management options.
A 54-year-old architect was admitted with a one-week history of a painful, swollen right arm. The patient was otherwise healthy with no significant past medical history and, in particular, no antecedent history of venous thromboembolism nor of trauma or heavy use of the limb. On examination, the right arm was grossly swollen, warm and erythematous with visible distension of the collateral veins. Ultrasound examination was performed which demonstrated a thrombus in the right axillary and subclavian veins.
Following discussion with radiology and vascular teams it was decided to undertake thrombolysis. Venography confirmed occlusion of the right axillary and subclavian with patency of the brachiocephalic and internal jugular beyond (Figure 1). A straight multisided catheter was used to lace the thrombus with approximately 10 mg tissue plasminogen activator (tPA) followed by an infusion of 0.5 mg/hour along with heparin via a sheath side arm. No immediate side-effects were encountered and the patient was transferred to ITU for monitoring. Follow-up angiography performed the subsequent day demonstrated that recanalization of the arm vessels had taken place and also that there was tight subclavian vein stenosis which required balloon dilatation. A radiograph of the cervical spine showed mild spondylosis but no cervical ribs or elongation to suggest bands. The patient was discharged home with a recommendation of at least six months warfarinization. On review, the patient has experienced no further swelling of the limb which is functionally normal allowing him to continue in his career unimpeded.
Axillosubclavian vein thrombosis is an uncommon condition accounting for approximately 4% of all deep vein thromboses (DVT).1 Although conventionally divided into primary and secondary forms, abnormalities such as external compression by a cervical rib or endothelial damage from strenuous use of the affected limb are almost always identified as risk factors in patients with ‘primary’ axillosubclavian vein thrombosis where more obvious causative factors, such as the presence of an indwelling venous catheter, are lacking. Other risk factors for secondary axillosubclavian thrombosis include hypercoagulable states2 and the presence of cardiac pacemakers.3 Although historically considered to be a relatively benign and self-limiting condition, axillosubclavian vein thrombosis is now increasingly recognized as a potential cause of significant consequences including pulmonary embolism4 and post-thrombotic syndromes.5
Primary axillosubclavian vein thrombosis includes Paget-von Schrötter syndrome or effort-induced thrombosis in which endothelial damage resulting from strenuous use of the affected, usually dominant, arm promotes clot formation. Venous compression, caused by a cervical rib or congenital fibromuscular bands for example, is also a frequent finding and thought to contribute to the formation of the thrombus resulting in stasis within the affected vein. This case demonstrates that although commonly reported in the literature, these risk factors are not universally present and their absence should not deter consideration of the diagnosis where examination findings are suggestive.
Management of axillosubclavian vein thrombosis remains a controversial issue. Earlier conservative treatment strategies involving rest and elevation of the limb with anticoagulation have been associated with high rates of residual chronic disability6 and treatment algorithms that include thrombolysis appear to be associated with fewer long-term complications.7 This case demonstrates successful outcome using local thrombolysis followed by balloon dilation of subclavian vein stenosis. No anatomical abnormalities of the thoracic outlet were identified in this case and, therefore, surgical intervention was not warranted.
The relative rarity of axillosubclavian vein thrombosis as opposed to lower limb DVT means large scale trials are sparse. In addition, the broad aetiology of the condition means that extrapolating data from the studies which are available may not always be relevant, especially in cases such as this in which classical risk factors are absent. Studies that have compared the effectiveness of local versus systemic thrombolysis in lower limb DVT have shown favourable results for catheter-directed thrombolysis.8 More large scale studies covering a wider range of patients are, however, needed in order to offer accurate and comprehensive advice on management for patients with axillosubclavian vein thrombosis.
IM wrote the initial manuscript after discussions with EB-H. EB-H subsequently wrote revisions to the text. RM provided ongoing supervisory advice about the clinical details of the patient and suggested clarifications to the text prior to submission. All three authors were involved in the patient's clinical care