|Year : 2012 | Volume
| Issue : 3 | Page : 202-204
Axillary vein thrombosis
S Joseph, Ali Raza, Ravi Raj Jadhav, Vishal Yadav
Department of Surgery, MGM Medical College, Navi Mumbai, India
|Date of Web Publication||10-Jun-2013|
103/A Sani Apartment, S.V. Road, Jogeshwari (West), Mumbai
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/0972-4958 .113256
We report a case of axillary vein thrombosis in a 45-year-old-man, sustained after fall of heavy object over the right upper limb. Three days later, a diagnosis of right distal axillary vein thrombosis was made. Patient was given subcutaneous low molecular weight heparin followed by oral warfarin. His symptoms disappeared after 3 months of treatment. It is important to be aware of this unusual but potentially serious complication, as early diagnosis and treatment may limit morbidity and mortality.
Keywords: Axillar vein thrombosis, Doppler, Thrombolytic therapy
|How to cite this article:|
Joseph S, Raza A, Jadhav RR, Yadav V. Axillary vein thrombosis. J Med Soc 2012;26:202-4
| Introduction|| |
Deep vein thrombosis in the upper limb is relatively rare. The main causes of such thrombosis include anatomical abnormalities in the costo-clavicular area, trauma, injuries sustained during central venous catheterization, use of intravenous drugs, and hyper-coagulable states. We present a case of right axillary vein thrombosis following fall of heavy object over elbow joint.
| Case Report|| |
A 45-year-old man presented to accident and emergency department with pain of recent onset in his right arm following fall of heavy object on his arm 3 days back. His arm was swollen, dusky and there was 3 × 3 cm abrasion over his right elbow joint [Figure 1]. He developed pain on full abduction and there was venous engorgement on the affected side.
|Figure 1 : The arm was swollen, dusky and a 3 × 3 cm abrasion over his right elbow joint|
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He was diagnosed to have soft-tissue injury with cellulitis and advised analgesics and a pouch arm sling. Three days after injury, he noticed swelling, heaviness, and tightness in his right upper arm. He denied any shortness of breath and chest pain.
On physical examination, swelling of the entire right arm was noted. He had a large bruise on the anterolateral aspect of the arm extending from the shoulder to the mid arm. His radiogram showed no bony injury and his distal neurovascular examination was normal. There was no jugular vein distension or dilated peripheral veins around the right shoulder.
A Doppler ultrasound of the right upper limb showed soft thrombus in lower half of right axillary vein [Figure 2]. No family history of hematological disorders. He gave a history of smoking 20 beedi/day for the last 15 years.
|Figure 2 : A Doppler ultrasound of the right upper limb showed soft thrombus in lower half of right axillary vein|
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All other aspects of history and examination were normal. Investigations showed an elevated hemoglobin, elevated hematocrit. D-dimer was elevated - consistent with a thrombosis.
The arm was elevated and the patient was given subcutaneous low molecular weight heparin for 3 days. He was then given intravenous unfractionated heparin followed by oral warfarin. The international normalized ratio was kept at 2.0-2.5.
The swelling reduced completely and he was discharged after 1 month. A repeat Doppler showed recanalization of thrombosed vein. Oral anticoagulants were continued for 6 months. He was advised to followed-up every 3 months in the 1 st year and then every 6 months for another 2 years.
| Discussion|| |
Deep vein thrombosis in the upper extremity is a rare but major thromboembolic complication, resulting in symptomatic, and fatal pulmonary embolism.  The underlying mechanisms of thrombosis are thought to be a venous compressive anomaly at the thoracic outlet or intimal damage due to a strain of the subclavian and axillary veins by retroversion or hyperabduction of the arm.  These movements are usually done during sport activities and deep vein thrombosis may occur in young adults with associated external compression of the vein by cervical ribs, malunited clavicle fractures, tumors, and hypertrophy of the scalene muscles. Other risk-factors described are estrogen ingestion, pregnancy, intravenous catheters, anti-neoplastic agents, and pacemakers. 
Although, early clinical recognition of UEDVT is important, diagnosis may be difficult because of its indeterminate cause and indistinct pathophysiology.
Symptoms are non-specific, vary in severity, may be position-dependent, and occasionally, the patient may be entirely asymptomatic.  Most commonly, the patient complains of initial heaviness in the affected arm, as well as a dull ache and pain of the involved limb. Other signs may include swelling of the shoulder and arm, discoloration and mottled skin, and distension of the cutaneous veins of the arm. A high index of clinical suspicion is required to detect and make a diagnosis. 
The treatment goals are to relieve the acute symptoms of venous occlusion, prevent pulmonary embolism, reduce the likelihood of recurrent thrombosis, and avoid development of post-thrombotic syndrome.  Thrombolysis and anticoagulation are the mainstay of treatment. Early diagnosis provides an opportunity for rapid venous recanalization with effective thrombolytic therapy. Suggested optimal period for thrombolytic treatment is within 6 weeks of the thrombosis.  Anticoagulants are used to prevent further deposition of the thrombus, allowing an established thrombus to stabilize, and to undergo endogenous lysis, reducing the risk of recurrent thrombosis.
Deep vein thrombosis has been reported in shoulder surgery, shoulder dislocations, and clavicle fractures. ,, In orthopedic practice, differentiation of deep vein thrombosis from skeletal injury and soft tissue injury is of paramount importance due to similar signs and symptoms produced by both. Moreover, the splintage given in soft tissue and bony injuries of upper extremity can easily hide the arm swelling produced by deep vein thrombosis.
Mechanism of injury in our case is not clear. The insult was of lesser magnitude to initiate thrombosis and no additional clotting abnormalities were noted. The patient did have a smoking history that might have predisposed him to venous thrombosis. Smoking has been shown to damage vascular endothelium, promote vascular thrombosis, and increase the relative risk of venous thromboembolism. Smoking more than 15 beedi/day can increase the relative risk twofold over that of age-matched non-smoking control subjects. 
Hyperabduction or stretching of the affected extremity may damage the intimal wall of the axillary or subclavian vein.  Although, such maneuvers are frequently without incident in daily life, in our patient, such a maneuver might have been sufficient to lead to thrombosis.
In conclusion, it is important to be aware of this unusual but potentially, serious complication as early diagnosis and treatment may limit morbidity and mortality. We must be aware of the symptoms of deep vein thrombosis of the upper extremity, and have a high index of suspicion as the symptoms can be easily attributed to the primary injury, resulting in failure to recognize a UEDVT.
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[Figure 1], [Figure 2]