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).
Right upper extremity venogram demonstrating acute right brachial deep venous thrombosis (DVT).
Right upper extremity venogram demonstrating acute right axillosubclavian vein deep venous thrombosis (DVT).
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.
Schematic of subclavian vein deep venous thrombosis (DVT) caused by compression from abnormal costoclavicular ligament.
ANATOMY AND PATHOPHYSIOLOGY
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.
Schematic of normal anatomy of the thoracic outlet.
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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