Download Axillary-Subclavian Vein Thrombosis

AXILLARY-SUBCLAVIAN VEIN THROMBOSIS
Rare Roman Gold Aureus, First century (c.75) AD, depicting the Emperor Vespasian,
Birmingham Museum.
“…his son Titus blamed him for even laying a tax upon urine, he (Vespasian) applied to
his nose a piece of the money…and asked him, if it stunk? And he replying “no”… “And
yet”… said he, “it is derived from urine!...”
Suetonius, “The Twelve Caesars”, Second century AD.
Titus Flavius Vespasianus, otherwise known to history as Vespasian, was one of ancient
Rome’s greatest Emperors. Ascending to the purple, in the year 69 AD, having been
proclaimed Emperor by his loyal legions of Egypt and of Judea, he quickly bought to an
end a year of turmoil within the Roman Empire. This year known as the year of the “four
Emperors” had seen, as the name suggests a succession of no less than four short lived
Emperors ascending the throne of Rome on the back of the brutal assassination of each
of their predecessors in turn. Even as Vespasian was acclaimed by his troops the third of
the four Emperors, Vitellius backed by the veteran legions of the Rhine and of Gaul
prepared to do battle against Vespasian. Vespasian was however a brilliant general,
having played a major role in the invasion of Britain under the Emperor Claudius in 43
AD when he was sent to subdue the southwest of the country. In 66 AD he was sent by
Nero to put down a major Jewish revolt in Judea. He quickly gained the ascendancy
there, and then turned his attention toward Vitellius. His troops entered Rome and once
strengthened by most of the other legions of the Empire who declared for him, Vitellius
was eventually defeated in furious fighting in the streets of Rome.
Following the defeat of Vitellius, he left his son Titus to complete the war in Judea and
set about restoring law and order within a Roman world that had been racked by
ceaseless civil war, the likes of which had not been seen since the days of Mark Antony
and Augustus, a century before. He restored discipline to the army which had become
utterly demoralized by 12 months of turmoil. In 70 AD, he overcame yet another
formidable rising in Gaul by a rebellious general who had allied himself with a number
of Gallic barbarian tribes and thus threatened the security of the entire Western half of
the Empire. For the next ten years he ruled with an “iron fist” which saw a period of
relative calm and prosperity return to the Roman world
Not only was he a strong leader of men and restorer of order, he also had an astute sense
of economic management, that none too many of his immediate predecessors had
possessed. With the cooperation of the Senate, he put the government and its finances on
a sound footing. He renewed old taxes and instituted new ones, increased the tribute of
the provinces, and kept a watchful eye upon potentially corrupt treasury officials. He
became known and even somewhat resented for the imposition of many strict and new
taxes, so much so that when he placed a tax on the use of the public urinals in Rome,
even his son Titus complained to his father that he had gone too far. Vespasian in a rage
pushed a coin into his son’s face a demanded to know if it “stunk”. His son replied that it
did not, whereupon Vespasian replied, “…yet it is derived from urine…!” Whatever it
took and by whatever means it took, Vespasian ruled the Roman world for 10 years with
an iron fist. No matter how desperate a state the Empire would find itself in, through
internecine civil war, rebellion or the threat of barbarian invasion he was able to prevail
by an iron discipline and a masterful eye for any opportunity to turn something, even
urine, into a positive for the Empire. In the opinion of most of his contemporaries he was
considered one of ancient Rome’s greatest.
In the 21st century there are many noble attributes of the Emperor Vespasian that may
still be applied to this day. He could turn almost anything into a “positive” for the good
of the Empire. When confronted with a patient with axillary vein thrombosis, we can turn
just as Vespasian did, even urine into a positive, not by a tax on it but by the extraction of
a substance known as urokinase.
AXILLARY-SUBCLAVIAN VEIN THROMBOSIS
Introduction
●
Axillary and subclavian vein thrombosis is an important diagnosis to make. The
incidence of pulmonary embolism and long term sequeale is high in untreated
cases.
●
Ealy referral should be made to the Vascular surgical unit in these cases.
Pathophysiology
Causes
1.
2.
Primary or spontaneous, (Paget-von Schrötters syndrome):
●
Many of these cases are thought to be effort induced, in association with
strenuous effort with the arm especially in the abducted position.
●
Seen in younger age groups (20-50 years) and especially in athletes.
Secondary causes:
●
●
Iatrogenic causes:
♥
Venous catheterisations,
malignancy.
♥
Following mastectomies.
♥
Radiotherapy.
in
patients
with
Adjacent pathological compressive lesions:
♥
Anatomical anomalies resulting in thoracic outlet obstructions
such as, congenital fibromuscular bands and cervical ribs.
♥
Malignancies,
lymphomas.
carcinoma
of
●
Procoagulation disorders.
●
Venous stenosis from previous scarring.
Complications
1.
especially
Pulmonary embolism.
the
lung,
(Pancoast
tumor)
●
The risk of this is relatively high, with up to 36% of cases resulting in
pulmonary embolism. 1
2.
Chronic recurrent pulmonary emboli, leading to pulmonary hypertension and right
sided heart failure.
3.
Chronic venous insufficiency with ongoing swelling and discomfort in the limb.
Clinical Features
1.
Non pitting edema of the upper limb.
2.
Mild cyanosis of the upper limb.
3.
Dilatation of subcutaneous collateral veins may be present over the upper arm and
chest.
4.
The veins on the back of the hand may not collapse when the hand is raised above
the level of the heart.
5.
Symptoms gradually subside as a collateral venous circulation develops, usually
over 2-3 months.
Investigations
Blood tests:
●
FBE, for any hematological abnormalities
●
U&Es/ glucose
●
A procoagulation screen
Ultrasonography:
●
Doppler ultrasound should be the initial imaging investigation for axillary vein
thrombosis.
Venography
●
Venography should be considered if the ultrasound is negative or inconclusive,
yet clinical suspicion remains high.
●
Subclavian vein thrombi are not reliably visualized by duplex ultrasonography.
●
Venography should still be considered following ultrasound confirmation of clot,
to look for possible venous abnormalities or other evidence of an obstructing
lesion. It will routinely be done following patients who have had thrombolysis.
CXR
●
Should be done in all cases to look for possible causative pathology, such as lung
carcinoma or cervical ribs, or other thoracic outlet obstructing lesions.
V/Q Scan
●
V/Q scan, threshold should be low if there is a clinical suspicion of pulmonary
embolism
CT scan
●
CT scan may be helpful in finding a thoracic lesion causing the thrombosis if
there is a suggestive lesion on CXR.
MRI
●
MRI, this is the most useful in the follow up investigation again to look for a
possible thoracic outlet anatomical lesion.
Management
All patients with this condition must be admitted for treatment under the vascular
unit.
1.
Thrombolysis:
Thrombolysis may be considered in the following cases:
●
Younger patients.
●
Acute (as opposed to chronic) presentations.
●
More extensive obstructive presentations.
Patients, who are candidates for thrombolysis, should be commenced on IV
heparin until review by the vascular unit for suitability for thrombolysis.
The preferred method of thrombolysis is regional IV urokinase infusion. The
radiology department will normally do this procedure, but there should also be
consultation with the Vascular unit.
2.
Clexane and warfarin:
●
Elderly patients and / or those with more minor signs and symptoms of
venous obstruction may be treated with clexane and warfarin in the first
instance, but should still be admitted under the Vascular unit.
3.
Surgical interventions:
Surgical interventions may include:
●
Embolectomy/ thrombectomy in selected patients.
●
Angioplasty and stenting may be done to maintain venous patency.
●
First rib resections.
●
Resections of fibromuscular bands.
●
The placement of SVC filters in cases of recurrent pulmonary emboli.
Disposition
Follow-up Vascular appointments need to be made for all these patients for further
investigation concerning the need for possible surgical intervention.
References:
1.
Bhimji Shabir, Subclavian Vein Thrombosis, in Thoracic Surgery in eMedicine
Website 5th October 2006
Dr J Hayes
Reviewed 4 May 2007