Axillary Vein Thrombosis

Synonyms: Paget-Von Schrötter syndrome, Axillary Subclavian Deep Vein Thrombosis (ASDVT), Upper-Extremity Deep Vein Thrombosis, Upper-Limb Deep Vein Thrombosis, Effort-Induced Thrombosis

Acute swelling and pain in upper limb due to occlusion of the axillary and/or subclavian veins by thrombus. May occur as a primary phenomenon or as a result of the placement of an indwelling venous catheter, thrombophilia or thoracic outlet syndrome.

Low incidence of about 2 per 100 000 people per year.¹ Historically only accounted for around 1-2% of all cases of DVT, but now more common due to the growing use of central venous cannulation in a variety of medical procedures. Occurs in about 25% of patients who under go prolonged central venous cannulation, although often not recognised. About 80% of primary cases occur in the dominant arm. It is also seen in young otherwise healthy individuals who participate in repetitive upper limb exercises.¹ One study reported that patients who had an upper limb deep vein thrombosis were more likely to be younger and with a lower BMI.²

Symptoms

• Patients tend to present promptly due to the acute discomfort and swelling
• Pain in axilla/around shoulder, often aching and indistinct
• Swelling of arm and hand
• Discolouration of the hand
• 7-20% of cases may lead to pulmonary embolism with features of pleuritic chest pain, breathlessness and haemoptysis¹

Signs

• Oedema of arm and hand - measure biceps/forearm diameter at a fixed distance from an anatomical landmark
• Mild to moderate cyanosis of the hand
• Dilated superficial collateral veins may be seen over the chest and upper arm - may be only indicator in central venous cannulation
• Fullness in the supraclavicular fossa and even a palpable cord of thrombosed vein
• JVP may be distended

• Superficial phlebitis
• Cellulitis
• Severe superficial bruising
• Muscular tear
• Intramuscular haemorrhage
• Lymphoedema
• Occult fracture
• Superior vena caval obstruction
• Lymphangitis
• Localised allergy
• Gas gangrene

• Duplex ultrasonography is sensitive and specific.
• Other imaging options include angiography or MRI angiography.
• It is uncertain whether routine thrombophilic screening in patients with this condition is worthwhile. It is probably useful where it occurs idiopathically, with a family history of thrombosis or history of recurrent miscarriage or previous DVT.
• Imaging investigations to detect thoracic outlet syndrome should depend on the degree of clinical suspicion of this cause.
• In idiopathic cases one should consider investigations to look for an occult malignancy or thrombophilia.

• Anticoagulation with low-molecular-weight heparin and warfarin as per lower limb DVT is the mainstay of management.
• The limb should be kept elevated and warm.
• Sufficient analgesia should be prescribed.
• Catheter directed thrombolysis has been used and minimises damage to the vessel.¹
• Percutaneous thrombectomy in combination with local thrombolysis may also be used.¹
• Early thrombolysis may reduce the incidence of long-term complications but this has not been proven in the total population of sufferers of the condition.
• Surgical thrombectomy may be needed in some cases.
• However, despite these options, the use of low-molecular-weight heparin and warfarin is also the mainstay of treatment in catheter related deep vein thrombosis - this can allow the central venous catheter to remain patent and in-situ.⁴

The use of anticoagulant prophylaxis in patients who are acutely ill and those who undergo central venous catheterisation may prevent upper extremity deep vein thrombosis. However, the efficacy of anticoagulant prophylaxis has not been clearly evaluated at present.²

• About 7-20% develop pulmonary embolism and 1% die.
• Recurrent thrombosis affects between 2 and 10% of patients.
• Post-thrombotic syndrome affects around 25% (see below).⁵

• PE has been detected on radiological grounds in up to 20% of patients with upper limb DVT (incidence highest in untreated/catheter cases)
• Phlegmasia caerulea dolens (PCD) may occur rarely; there is arterial and venous compromise and a risk of gangrene
• Compartment syndrome
• Recurrent thrombosis
• Post-thrombotic syndrome - chronic upper limb pain and swelling
• Stroke following paradoxical embolisation in cases with a patent foramen ovale
• Right ventricular failure
• Thoracic duct obstruction
• Chylous pleural or pericardial effusion