"EFFORT" THROMBOSIS OF THE AXILLARY VEIN WITH PULMONARY EMBOLISM

Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher

Context:

Effort thrombosis, or Paget-Schroetter’s syndrome, is a rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion. It is occasionally associated with pulmonary embolism. This case of effort thrombosis and pulmonary embolus was in a 25-year-old major league professional baseball pitcher, in which the only presenting complaints involved dizziness and shortness of breath without complaints involving the upper extremity—usually, a hallmark of most cases of this condition. The patient successfully returned to play for 5 subsequent seasons at the major league level after multimodal treatment that included surgery for thoracic outlet syndrome.

Objective:

Though rare, effort thrombosis should be included in the differential diagnosis of throwing athletes with traditional extremity-focused symptoms and in cases involving pulmonary or thoracic complaints. Rapid diagnosis is a critical component of successful treatment.

Superior Vena Cava Perforation Following the Placement of a Superior Vena Cava Filter in Males Less than 60 Years of Age

Although the utility of the superior vena cava (SVC) filter remains controversial, the safety and efficacy of SVC filters in patients with upper extremity deep venous thrombosis in whom anticoagulation is contraindicated or ineffective have been well described. However, few complications have been reported. Herein we describe a series of three cases of SVC perforation in three young males following the placement of SVC filters. All three patients had deep venous thrombosis on upper extremity duplex ultrasonography and contraindication to anticoagulation ( n = 1) or failure of anticoagulation ( n = 2). Cardiac tamponade was demonstrated on transthoracic echocardiography in all three cases. The pericardial effusion was evacuated with either median sternotomy or pericardiocentesis in two cases. One of the patients died of cardiac arrest, and an autopsy showed aortic perforation in addition to the SVC perforation. This patient underwent chest compression following the cardiac arrest. One patient was lost to follow-up, and the other patient remained asymptomatic at the 1-year follow-up. This is the first case of SVC perforation that is associated with aortic perforation after the placement of an SVC filter. Owing to this occurrence, one has to be aware of these life-threatening complications when placing an SVC filter, especially in males less than 60 years of age.

Internal Jugular, Subclavian, and Axillary Deep Venous Thrombosis and the Risk of Pulmonary Embolism

The objective of this study was to investigate the risk of acute internal jugular, subclavian, and axillary deep venous thrombosis (upper torso DVT [UTDVT]) and pulmonary embolism (PE) and the role of anticoagulation in a cohort of hospitalized patients.

A 2-year retrospective review of hospitalized patients who underwent upper torso vein duplex scanning was performed. Patient demographics, underlying comorbidities, indication for scanning, diagnostic tests, intensive care unit stay, length of stay, presence of a central line (current or within the last 2 weeks), malignancy (current or former), hypercoaguable condition, postoperative state, renal failure, mortality, and use of anticoagulation were recorded. Univariate and multivariate analyses were performed to investigate significant risk factors for acute UTDVT. The impact of an acute UTDVT and use of anticoagulation on hospital length of stay, survival to 30 days and 1 year, and PE rate were calculated.

One hundred eighty-nine patients were scanned. Sixty-three patients (33%) were found to have an acute UTDVT. The internal jugular vein was the most common site of thrombosis. The presence of a central venous catheter was the only factor found to be a significant risk factor for an acute UTDVT ( p = .03). Five patients (7.9%) with an UTDVT had a PE documented by computed tomographic angiography-pulmonary arteriography, and all had an internal jugular thrombosis (four isolated and one combined with an axillary-subclavian thrombosis). No PE was fatal. Thirty-eight (60%) patients with an acute UTDVT were treated with therapeutic anticoagulation; the remainder were observed. All patients with a PE received anticoagulation. Hospital length of stay, 30-day mortality, and 12-month survival were no different for patients with and without an UTDVT ( p = .7). The use of anticoagulation had no observable effect on survival in patients with UTDVT ( p = .1).

An acute internal jugular, subclavian, or axillary DVT is a relatively common finding in the hospitalized patient. Patients with a central line (current or within the previous 14 days) were at greatest risk, with an internal jugular vein thrombosis being the most common source. The inconsistent use of anticoagulation therapy for UTDVT was associated with a moderate risk of PE. A survival benefit for anticoagulation could not be documented.

Clinical experience with superior vena caval Greenfield filters

PURPOSE

To evaluate the results of superior vena caval (SVC) Greenfield filters in patients at risk for pulmonary embolism (PE) secondary to upper extremity deep venous thrombosis (UEDVT).

METHODS

Over a 46-month period, 26 patients (10 men, mean age 67 years, range 25 to 89) with UEDVT in whom anticoagulation was contraindicated (n = 22) or ineffective in preventing recurrent PE or extension of the thrombus (n = 4) were treated with placement of SVC Greenfield filters.

RESULTS

One SVC filter was misplaced into the innominate vein but left in place; this vein remains patent after 2 months without evidence of filter migration. Follow-up ranged from 10 days to 46 months (mean 7.8 months). Fifteen (58%) patients died inhospital of causes unrelated to the SVC filter or recurrent thromboembolism (mean time to death 36 days). Of the 11 survivors, follow-up ranged from 1 to 38 months (mean 22). Sequential chest roentgenograms in 9 (82%) patients revealed no filter migration or displacement. No evidence of PE was found in any of the survivors over the course of follow-up.

CONCLUSIONS

Insertion of SVC Greenfield filters is a safe and feasible therapy to prevent recurrent thromboembolism in patients with UEDVT who are refractory to or inappropriate for anticoagulation therapy.

Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population

PURPOSE

Although much attention has been focused on lower extremity deep venous thrombosis (LEDVT), there is a relative paucity of data regarding the impact of upper extremity deep venous thrombosis (UEDVT) on morbidity and mortality rates. To increase our knowledge with the latter disease, we have reviewed our experience at our institution with 170 patients who had brachial, axillary, and subclavian vein thromboses.

METHODS

Over the past 5 years, UEDVT was diagnosed in 170 patients by duplex scanning. The indications for duplex examination were either upper extremity swelling (95%) or as part of the workup for pulmonary embolism (5%). There were 103 women (61%) and 67 men (39%), with ages ranging from 9 to 101 years (mean, 68 +/- 17 years). The diagnosis was made in 152 patients (89%) while they were admitted to the hospital and in 18 patients (11%) in the outpatient clinic. Risk factors included presence of a central venous catheter or pacemaker in 110 patients (65%), malignancy in 63 patients (37%), concomitant LEDVT in 19 patients (11%), and history of LEDVT in 18 patients (11%). Fifty-six patients (33%) had multiple risk factors, whereas 36 patients (21%) had no obvious risk factor.

RESULTS

The 1-month and 3-month mortality rates for the entire study group were 16% and 34%, respectively. Patients who had concomitant LEDVT, were 75 years of age or older, and were not treated with anticoagulation medication had a significantly higher 1-month mortality rate. Patients whose diagnoses were made in the outpatient setting were statistically younger and had a lower 3-month mortality rate when compared with the patients whose diagnoses were made as inpatients. Pulmonary embolism was documented by ventilation/perfusion scan in 12 patients (7%). Although no patient in the group in which UEDVT was diagnosed on an outpatient basis was documented to have a pulmonary embolism and 12 patients (8%) in the inpatient group had pulmonary emboli, this difference was not statistically significant. Anticoagulation medication did not totally prevent pulmonary embolism in this review. All patients were followed-up for between 0 to 49 months (mean, 13 +/- 1 months). No swelling of the affected arm was observed in 145 patients (94%); four patients complained of mild intermittent swelling (2%), and seven patients reported significant swelling (4%).

CONCLUSIONS

Contrary to previous reports, these data suggest that UEDVT is associated with a low incidence of postthrombotic upper extremity swelling, but a significant incidence of pulmonary embolism and rate of mortality. This review suggests that UEDVT is at least as serious a disease entity as LEDVT and should be managed as aggressively as LEDVT.

Pulmonary embolism from axillosubclavian thrombosis on a rehabilitation unit: case report

This report presents a case of angiogram-confirmed pulmonary emboli (PE) from upper extremity deep venous thrombosis (UE DVT) in a patient with Guillain-Barré syndrome. UE DVT has been rarely reported in the rehabilitation literature and it is not described in many standard references in the field. Risk factors for UE DVT include central venous catheterization (CVC), stasis, and hypercoagulability. Rehabilitation patients commonly demonstrate these risk factors, as well as unilateral limb swelling and pain. Although early reports emphasized the rarity of PE from UE DVT, it is now reported in roughly 12% of cases, and there may be an even higher incidence in CVC-related UE DVT. This report includes a review of etiologic, anatomic, diagnostic, and therapeutic considerations, and concludes with a discussion of the potential underrecognized significance of UE DVT in the general rehabilitation population.

A multidisciplinary approach to the treatment of Paget-Schroetter syndrome

To assess the results of thrombolytic therapy and surgical decompression of the thoracic outlet in the management of spontaneous axillary vein thrombosis (AVT), the records of 38 patients at New York University Medical Center (NYUMC) with AVT were reviewed. Excluded from this report were 20 patients who had AVT secondary to an underlying medical condition, a subclavian catheter, or a failed dialysis access graft. Of the 18 remaining patients with no underlying medical condition, all were found to have effort-related axillo-subclavian thrombosis, Paget-Schroetter syndrome. Urokinase was used for thrombolysis in 17 of the 18 patients, (94.4%) with complete lysis in 14 (82.4%). The remaining patient received anticoagulation only following a favorable response to an initial heparin infusion. Of the patients achieving complete thrombolysis, all but one received urokinase within 8 days of the onset of symptoms. Clot lysis revealed axillary vein compression secondary to a thoracic outlet syndrome in 11 patients, and these underwent staged transaxillary thoracic outlet decompression by first rib resection. All 17 patients have been followed for a mean of 21 months, and none receiving lytic therapy have reoccluded. Review of these data confirms earlier reports showing that with early diagnosis, thrombolysis and, if indicated, thoracic outlet decompression, patients with spontaneous AVT can expect excellent clinical results with a good long-term prognosis.

Deep venous thrombosis of the upper extremity: diagnosis and treatment

Deep vein thrombosis of the upper extremity was long thought to be a benign disease, rarely complicated by pulmonary embolism and associated with minimal long-term morbidity. More recent observations have demonstrated however, that a significant number of patients will continue to have disabling symptoms after treatment with conservative measures and standard anticoagulation therapy, and that pulmonary embolism can occur in the course of the disease. Because of its significant morbidity and increasing incidence, an aggressive emergency department approach to diagnosis and early consideration of fibrinolytic therapy are recommended.

Diagnostic and therapeutic approach to axillary-subclavian vein thrombosis

We report the cases of four patients who complained of post-exertional shoulder and/or arm discomfort, and who were diagnosed with acute or possible impending axillary-subclavian vein thrombosis. One regained full patency of a stenotic and obstructed vein after local streptokinase infusion, first rib surgical resection, and transvenous angioplasty. A second with a patent but narrowed and tented vein was treated with heat and elevation, and was referred for possible surgical correction of thoracic outlet syndrome. The third patient, who presented two weeks after the thrombotic event, experienced a poor clinical outcome characterized by recurrent thrombosis despite aggressive therapy. The fourth, whose thrombosis was the presenting sign of mediastinal lymphoma, was treated with heat and elevation with resolution of pain and swelling.

Pulmonary embolus after treatment for subclavian-axillary vein thrombosis

Treatment of effort-induced subclavian-axillary vein thrombosis of the upper extremity is aimed at elimination of the chronic symptoms of the postphlebitic syndrome. Various treatments have been tried, with varied success. Recently, fibrinolytic therapy with streptokinase (Abbokinase) or urokinase (Kabikinase, Streptase) has gained popularity as a treatment option. In the case presented here, complete lysis of effort-induced subclavian-axillary vein thrombosis was achieved with the use of catheter-directed infusion of streptokinase. Subsequently, a pulmonary embolus developed, causing marked morbidity. It is likely that fibrinolytic therapy was directly responsible for this complication. The current literature does not support routine use of fibrinolytic agents in the treatment of effort-induced thrombi of the upper extremity, since these agents can cause significant morbidity. We conclude that fibrinolytic therapy should be reserved for life-threatening conditions, such as myocardial infarction, massive pulmonary emboli, and significant arterial occlusions.

Pathogenesis determines late morbidity of axillosubclavian vein thrombosis

The late consequences of axillosubclavian vein thrombosis were evaluated through a clinical follow-up of 41 patients (45 limbs) treated from July 1975 to December 1985. The causes of the obstruction were classified into two main groups: Intrinsic damage, consisting of thrombophlebitis due to intravenous drug abuse (11 patients), central venous catheterization (10 patients), and hypercoagulability state (2 patients); and extrinsic obstruction, involving effort-induced or thoracic outlet obstruction (9 patients), underlying neoplastic disease (5 patients), trauma (3 patients), and congenital venous malformation (1 patient). Clinical diagnosis was confirmed by upper arm venography in all 41 patients, and all were initially treated by anticoagulation with heparin for 1 to 2 weeks, usually followed by oral warfarin for a variable period of 1 week to 5 years. Only three patients had an operation (rib resection for thoracic outlet obstruction, thrombectomy and clavicle fixation, and repair of a congenital venous malformation). Major early morbidity consisted of a documented pulmonary embolus in five patients, two in Group I and three in Group II, for an overall incidence of 12 percent. Clinical follow-up of up to 5 years revealed that chronic morbidity was related to our classification. Thrombosis secondary to intrinsic damage rarely caused persistent symptoms and responded well to anticoagulation alone. Conversely, when extrinsic obstruction was the cause, only 50 percent of patients were symptom-free, whereas many had disabling intermittent arm swelling and pain. Repeat venography in severely symptomatic patients revealed persistent obstruction with no recanalization. We conclude that patients with axillosubclavian venous thrombosis due to intrinsic damage do not require treatment other than anticoagulants, whereas patients with extrinsic obstruction often have poor long-term results from conventional therapy and therefore should be considered for adjunctive treatment with thrombolysins or operative intervention.

"Effort" thrombosis of the subclavian vein in a competitive swimmer

"Effort" thrombosis is a unique form of subclavian and axillary vein thrombosis because it is the result of an unusual variant of the thoracic outlet syndrome. Another cause of subclavian vein thrombosis is local compression from trauma, tumor, or development anomalies; a third is intimal damage from indwelling central venous catheters. This is a case report of "effort" thrombosis of the subclavian vein in a competitive swimmer. A recently developed technique of local infusion of low-dose streptokinase therapy is used for clot lysis. Early diagnosis is essential for effective thrombus dissolution with streptokinase. The rationale, risk, and method of streptokinase administration are discussed. Since "effort" thrombosis is secondary to thoracic outlet syndrome (TOS), decompression of the thoracic outlet by removal of the first rib after clot lysis is recommended.

Pulmonary embolism secondary to venous thrombosis of the arm

Pulmonary embolism is described as an infrequent complication of axillary and subclavian vein thrombosis. We have reported our recent clinical experience with 14 patients admitted to the Harbor-UCLA Medical Center who had a clinical diagnosis of axillary and subclavian vein thrombosis documented by phlebography of the thrombosed arm. The causes of thrombosis were effort (three patients), trauma (three patients), drug abuse (four patients), underlying neoplastic disease (three patients), and congenital venous malformation (one patient). Pulmonary emboli were diagnosed by arteriogram, ventilation perfusion scans, and arterial blood gas abnormalities in five patients with respiratory symptoms for an incidence of 35.7 percent. Immediate anticoagulation with heparin, then switching to warfarin sulfate after 5 days, was the standard therapy in all patients. Follow-up examinations between 3 and 24 months demonstrated mild postphlebitic syndrome consisting of pain and minimal swelling in two patients. We conclude that pulmonary emboli may be a more frequent complication of axillary and subclavian vein thrombosis than has generally been recognized.

Subclavian thrombosis following hockey injuries

Subclavian thrombosis is not an uncommon disease following an injury. It has been reported following severe trauma to mere hyperabduction of the arm. Heretofore it has not been reported following a hockey injury. I wish to report two cases where subclavian thrombosis occurred following a hockey injury. The records of the National Hockey League for a 3-year period along with the world literature have been reviewed. The mechanisms producing the thrombosis and pathogenesis are described along with the modes of diagnosis and treatment.

"Effort thrombosis" of the subclavian vein associated with oral contraceptives

We report a case of "effort thrombosis" of the subclavian vein in a 33-year-old woman with several thrombotic risk factors, including the use of oral contraceptives. The signs and symptoms associated with this syndrome, as well as concepts concerning diagnostic techniques and management, are discussed.