Axillary-Subclavian Vein Thrombosis - developinganaesthesia



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. 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.

2. Secondary causes:

● Iatrogenic causes:

♥ Venous catheterisations, especially in patients with malignancy.

♥ Following mastectomies.

♥ Radiotherapy.

● Adjacent pathological compressive lesions:

♥ Anatomical anomalies resulting in thoracic outlet obstructions such as, congenital fibromuscular bands and cervical ribs.

♥ Malignancies, carcinoma of the lung, (Pancoast tumor) lymphomas.

● Procoagulation disorders.

● Venous stenosis from previous scarring.

Complications

1. Pulmonary embolism.

● 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

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