Axillary vein thrombosis

What anticoagulation for axillary vein thrombosis?
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Axillary vein thrombosis also known as paget-schroetter syndrome is a condition characterized by the formation of a blood clot (thrombus) within the axillary vein, which is located in the armpit area.

This thrombosis can lead to swelling, pain, and potential complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

It can occur spontaneously or as a result of various factors such as trauma, prolonged immobilization, or underlying medical conditions like cancer or clotting disorders which also may lead to subclavian vein thrombosis.

Treatment typically involves anticoagulant therapy to prevent clot extension and reduce the risk of complications.

What vein thrombosis?

A less common condition known as axillary vein thrombosis (vein thrombosis of the upper) can be considered as the upper limb’s version of deep venous thrombosis.

Epidemiology

  • The incidence of this condition is relatively low, affecting approximately 1 out of every 100,000 individuals per year.
  • The upper-extremity deep vein thrombosis accounts for 4-10% of all cases of deep vein thrombosis (DVT).
  • This condition has become more prevalent as the use of central venous cannulation has grown in various medical procedures.
  • Approximately 25% of patients who undergo prolonged central venous cannulation experience this condition, although it often goes unnoticed.
  • The dominant arm is affected in around 80% of primary cases.
  • It can also occur in young and otherwise healthy individuals who regularly engage in repetitive upper limb exercises.

What are risk factors of axillary vein thrombosis?

  • The likelihood of being affected by upper extremity deep vein thrombosis increases when someone engages in activities that require repetitive movements of the arms and shoulders, such as baseball, softball, basketball, hockey, swimming, tennis, and weightlifting.
  • Jobs that require repeated use of arms, such as construction work, painting, or window cleaning, are at higher risk.
  • People with clotting disorders and catheter-related thrombosis.
  •  People with a central venous catheter in the subclavian vein, especially those undergoing chemotherapy or Hemodialysis, are also at greater risk.
  • People wearing pacemakers or defibrillators should be alert to this situation when wires pass through the area.

What are signs and symptoms of axillary vein thrombosis?

The signs and symptoms of axillary vein thrombosis can include:

  1. Onset of Swelling of upper extremity venous thrombosis: The thrombosis in the upper arm may experience noticeable swelling, which can occur suddenly or gradually.
  2. Arm Pain and Sensitivity: Pain or sensitivity in the arm, particularly in the armpit area or along the path of the axillary vein.
  3. Changes in Skin Color: Decreased blood flow can cause the skin above the affected area to appear red, bluish, or have a dusky discoloration.
  4. Increased Skin Temperature: Inflammation and increased blood flow can make the skin above the affected vein feel warmer than usual.
  5. Detectable Lump or Cord-like Structure: The presence of a thrombus may be indicated by the ability to feel a lump or a cord-like structure along the path of the axillary vein.
  6. Numbness or Tingling Sensations: Compression of nearby nerves by the thrombus can result in numbness, tingling, or weakness in the arm or hand.
  7. Limited Arm Movement: Severe cases of axillary vein thrombosis can restrict arm movement due to pain, swelling, and reduced flexibility.
  8. Expansion of the Vein: If the thrombus is large or extends into nearby veins, the affected vein may appear distended or engorged.
  9. Prominent Alternate Veins: In certain instances, noticeable alternate veins may develop as the body tries to redirect blood flow around the blocked vein.
  10. Overall Symptoms: Individuals with axillary vein thrombosis, although rare, may experience systemic symptoms such as fever, chills, or a general feeling of illness, especially if there is an associated infection or inflammation.

What is differential diagnosis of axillary vein thrombosis?

  • Superficial phlebitis.
  • Cellulitis.
  • Marked bruising on the surface.
  • Tear in the muscles.
  • Bleeding within the muscles.
  • Lymphedema.
  • Hidden fracture.
  • Blockage of the superior vena cava.
  • Inflammation of the lymphatic vessels.
  • Allergic reaction in a specific area.
  • Development of gas gangrene.

What are investigations of axillary vein thrombosis?

The examination of choice is ultrasonography, either Doppler or color Doppler, for compression which helps diagnose thrombosis in the upper extremity.

For lower extremity thrombosis, D-dimer testing is of less benefit, especially in hospitalized patients with central venous catheters or malignancy.

For patients with suspected upper extremity DVT, CT examination or magnetic resonance venography is recommended if no thrombosis is detected on the first ultrasound examination despite a high clinical suspicion of DVT.

The value of routine thrombophilia screening in patients with this disease is uncertain. However, it may be useful in idiopathic cases, have a family history of thrombosis, have a history of recurrent miscarriage, or have a history of previous DVT.

The choice of imaging studies to detect thoracic outlet syndrome should be based on clinical suspicion of the cause.

In cases of idiopathic origin, it is important to consider testing to look for occult malignancy or thrombophilia.

Axillary vein thrombosis - Dr/Farouk Marzouk

What are complications of axillary vein thrombosis?

Patients with upper extremity deep-vein thrombosis and also vein compression either upper-extremity deep venous thrombosis or lower may have some serious complications:

  • Pulmonary embolism has been detected on radiological grounds in up to 20% of patients with upper-limb DVT (incidence is highest in untreated/catheter cases).
  • Phlegmasia Caerulea Dolens (PCD) may occur (rarely); there is an arterial and venous compromise with a risk of gangrene.
  • Compartment syndrome.
  • Recurrent thrombosis and repeated compression in venous thoracic outlet syndrome causes the vein to become inflamed and fibrous tissue to build up.
  • Post-thrombotic syndrome – chronic upper-limb pain and swelling.
  • Stroke following paradoxical embolization in cases with a patent foramen ovale.
  • Right ventricular failure.
  • Thoracic duct obstruction.
  • Chylous pleural or pericardial effusion.

How to management of axillary vein thrombosis?

Management of upper extremity deep vein thrombosis (DVT) in axillary and subclavian veins can be administered either in a hospital setting or on an outpatient basis when suspected upper extremity deep vein, depending on your condition.

In the management of deep vein thrombosis (DVT), there are various approaches encompassing the utilization of medications, application of compression stockings, elevating the affected leg, and in cases where the blood clot is widespread, resorting to more invasive diagnostic and treatment techniques.

The primary objectives in addressing this condition are to:

  • To halt the enlargement of the clot.
  • To ensure that it does not detach from the vein and migrate to the lungs.
  • To diminish the probability of experiencing another blood clot and prevent the development of chronic venous insufficiency or post-thrombotic syndrome.
  • To avoid long-term complications associated with the blood clot.

Some medications which may be useful:

1. Anticoagulants, also known as blood thinners, diminish the clotting capability of your blood, resulting in the prevention of clot enlargement and the movement of existing blood clots. These medications are commonly administered to hospitalized individuals to impede clot formation.

It is important to note that anticoagulants do not directly disintegrate established blood clots.

Instead, they rely on your body’s innate mechanisms to potentially dissolve the clot. Nevertheless, it should be acknowledged that there are occasions where the clot may persist, failing to fully dissolve.

Examples for anticoagulant medications:

Warfarin (Coumadin) or as an injection or shot.

Heparin (or low molecular weight heparin).

2. Thrombolytics therapy: thrombolytic therapy is administered to expedite the dissolution of a blood clot.

The delivery of these medications occurs via a catheter, which is guided to the site of the clot.

The primary purpose of employing thrombolytics is to alleviate the distressing symptoms caused by extensive clots.

3. Direct thrombin inhibitors are medications that interfere with the clotting process.

4. Compression stockings:

To address the persistent swelling that may arise following the formation of a blood clot, it is recommended that your medical practitioner prescribe graduated compression stockings.

Some additional procedures may be useful:

  • If you find yourself seated for extended periods, make sure to exercise your lower leg muscles.
  • Take short walks every hour while you are awake.
  • Ensure you do not wear tight clothes that impede blood flow in your legs.
  • Follow your doctor’s recommendation and wear compression stockings.
  • Steer clear of activities that carry the risk of serious injury.
  • Catheter-directed thrombolytic therapy is a non-surgical method to dissolve blood clots in DVT.

How to prevent axillary vein thrombosis?

Anticoagulant prophylaxis can be beneficial for patients experiencing acute illness or undergoing central venous catheterization to prevent upper-extremity DVT.

Moreover, patients face a potential risk of lower-limb thrombosis, underscoring the importance of anticoagulant prophylaxis in this context as well.

What is prognosis of axillary vein thrombosis?

Linked to considerable morbidity and mortality are the potential dangers of pulmonary embolism, post-thrombotic syndrome, and the loss of vascular access.

• Pulmonary embolism emerges in approximately 10-20% of cases.

• Mortality rates have been documented to range from 15-50%, primarily contingent on the root cause.

• Affecting between 2% and 5% of individuals are recurrent thrombotic episodes.

• The occurrence of post-thrombotic syndrome stands at 13%, as detailed in the ‘Complications’ section.

Finally:

The incidence of upper extremity deep venous thrombosis has increased significantly due to the greater use of intravenous catheters in the upper extremities.

This type of catheter is mainly used for interventional treatments such as superior vena cava syndrome.

Symptomatic upper extremities venous thrombosis in the upper limbs is often associated with thrombosis (thrombotic disease), thoracic malignancy, subclavian vein cannulation or use of peripheral intravenous access, excessive physical exertion, and trauma.

Diagnostic imaging plays a key role in identifying upper extremity deep venous thrombosis and assessing the effectiveness of treatment.

Among the available options, CDUSG is the diagnostic method of choice due to its noninvasiveness, ease of performance, reproducibility, and relatively low cost.

The main goals of upper extremities deep vein thrombosis treatment are symptom relief, early return to normal activities, prevention of recurrence, and minimization of treatment time and cost.