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PATIENT STORY

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A previously healthy 22-year-old man presents with a 3-day history of right upper extremity swelling and pain. He is a competitive cross fit athlete and performs vigorous upper body weight lifting several days per week. On examination the right forearm and brachium are diffusely swollen with an overlying erythrocyanotic appearance. A venous duplex ultrasound identifies acute thrombosis within the axillary and subclavian veins. In preparation for catheter-directed thrombolysis, a right upper extremity venogram is performed. Figures 56-1A and B venographically illustrate diffuse intraluminal filling defects consistent with acute brachial and axillosubclavian deep vein thrombosis (DVT).

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FIGURE 56-1A

Right upper extremity venogram demonstrating acute right brachial deep venous thrombosis (DVT).

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FIGURE 56-1B

Right upper extremity venogram demonstrating acute right axillosubclavian vein deep venous thrombosis (DVT).

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EPIDEMIOLOGY

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  • Primary effort-related thrombosis of the subclavian vein caused by compression within the thoracic outlet (Figure 56-2A).

  • Provocative arm positioning includes repetitive hyperabduction and external rotation of the upper extremity or posterior and inferior shoulder rotation.

  • Absence of other causes, such as extrinsic mass or indwelling catheter.

  • Male-to-female ratio is approximately 2:1.1

  • Mostly in third and fourth decades of life.1,2

  • Young, healthy athletes after vigorous upper extremity exercise and in patients who do frequent overhead maneuvers (painters, construction workers, wood choppers, auto repair workers).1

  • Involves the dominant arm in 80% of cases.

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FIGURE 56-2A

Schematic of subclavian vein deep venous thrombosis (DVT) caused by compression from abnormal costoclavicular ligament.

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ANATOMY AND PATHOPHYSIOLOGY

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  • The subclavian vein passes through the thoracic outlet bounded by the clavicle and subclavius muscle anteriorly, the anterior scalene muscle laterally, the first rib posterior-inferiorly, and the costoclavicular ligament medially (Figure 56-2B).

  • Extrinsic compression of the subclavian vein by the first rib and the clavicle.1,2, and 3

  • Hypertrophy of the anterior scalene muscle and/or the subclavius muscle can decrease the size of the outlet and compress the subclavian vein.1

  • Multifactorial pathophysiology that fulfills the Virchow triad including (1) anatomic changes listed above leading to stasis; (2) hypercoagulability in association with exercise-associated stress; (3) intimal tears within the vein wall in association with repetitive shoulder-arm movement.

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FIGURE 56-2B

Schematic of normal anatomy of the thoracic outlet.

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DIAGNOSIS

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Clinical Features

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  • Young patient presenting with blue, heavy, swollen, painful arm.1

  • History of vigorous exercise or activity with the affected extremity, usually within the previous 24 hours.1,2

  • Dull aching pain within the ...

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