What are the causes and treatments of venous thrombosis in the arm? By PHILIP COLERIDGE SMITH DM MA BCh FRCS Consultant Vascular Surgeon, Medical Director of the British Vein Institute and Emeritus Reader in Surgery at UCL Medical School
[VENOUS THROMBOSIS in the arm is far less common
than in the leg, but may give rise to troublesome symptoms. Problems in the arm may occur in young people as part of ‘thoracic outlet syndrome’ in which the veins, arteries or nerves to the arm become compressed as they leave the chest to reach the arm.
Causes of venous thrombosis in the arm
The blood supply to the arm comes from inside the chest. The subclavian artery arises from a major branch of the aortic arch in the chest and passes under the clavicle and over the first rib to enter the arm. On the way back to the heart, the subclavian vein takes a similar route and joins the large veins in the upper part of the chest before draining back to the heart. The nerves to the arm arise in the neck and again pass between the first rib and clavicle. A group of related conditions arise when the gap Prominent veins over the front of the left shoulder in a patient with a history of between the first rib and the clavicle is too narrow for the previous subclavian vein thrombosis blood vessels and nerves. That can arise as a result of a congenital abnormality or after injury leading to fractures However, other options include thrombolytic treatment to remove of the ribs or clavicle. The resulting syndromes are known collectively venous thrombosis and stenting of the reopened vein to prevent it as ‘thoracic outlet syndrome’. Compression of the nerves to the arm closing again. The initial problem causing the venous thrombosis is leads to pain in the arm, mainly in the hand. The subclavian artery may the reduced opening between the first rib and the clavicle. That can suffer thrombosis if compressed, leading to ischaemia of the arm. The be opened by excising the first rib, which is effective in the venous, subclavian vein can also suffer thrombosis leading to swelling in the arm. arterial and neurological types of thoracic outlet syndrome. Subclavian vein thrombosis may occur in body builders and athletes Clinical series, but not randomised clinical trials, have been – more commonly in men, but women may also be affected. Young published in which those methods of management have been adults are often affected. The condition is sometimes known as evaluated. All show potential advantages in skilled hands. Potential ‘effort thrombosis’ or eponymously as ‘Paget Schroetter syndrome’. defendants are likely to point out that detailed evidence of efficacy of General causes of thrombosis, such as inherited conditions leading to those treatments has not been published and a wide range of clinical thrombosis and the oral contraceptive pill, may also be factors. practice is considered to be acceptable in vascular surgical practice. Iatrogenic causes of subclavian vein thrombosis are common these That is likely to lead to difficulty with any claimant’s liability and days. They arise from the use of central venous catheters in intensive causation cases. care units. That has been a common problem arising during the COVID-19 pandemic, since that infection is also a strong risk factor Outcome of upper limb venous thrombosis for thrombosis. Treatment of patients with cancer often necessitates In many patients the blocked subclavian vein will develop a new injections via a central venous catheter. The combination of cancer and channel after a period of anticoagulant treatment. A larger proportion the catheters may lead to venous thrombosis. The subclavian vein is of veins appear to regain blood flow after thrombolytic treatment. a common route by which central venous catheters reach large veins In some patients swelling in the arm disappears as the thrombus near the heart. is reabsorbed. Collateral venous drainage may develop around the shoulder and prominent veins may appear over the chest (pictured). Deep vein thrombosis of the upper limb Some patients develop pain or heaviness in the arm after short Acute venous thrombosis in the upper limb veins presents as periods of exercise, while in others the neurological features such as swelling of the arm, combined with dusky discolouration due to venous pain in the arm or hand may become more troublesome. congestion. The venous obstruction is readily seen on ultrasound Solutions for patients with persistent symptoms include resection imaging, as is the case with DVTs arising in the lower limb. of the first rib or venous bypass procedures, so even when a venous In general, anticoagulant treatment with heparin or modern oral thrombosis has a poor initial outcome it can be improved with anticoagulants is recommended for upper limb venous thrombosis. additional treatment. NICE has offered very detailed advice on the investigation and In conclusion, venous thrombosis in the upper limb may arise from treatment of deep vein thrombosis of the lower limb in NICE Guideline a number of causes. Anticoagulant treatment is accepted practice, but 158; however, that document offers no advice on the management other than that a wide range of clinical practice is considered to be of venous thrombosis in the arm. As a result, no detailed guidelines acceptable management. In patients with a poor late outcome, surgical for management are available, which makes litigation regarding the solutions including first rib resection or venous bypass operations may condition much more difficult. In general, it would be considered improve the outcome. The diversity of medical opinion in this field of substandard practice to manage an upper limb thrombosis without medicine makes litigation unsatisfactory or infeasible in many cases. q anticoagulant treatment. www.yourexpertwitness.co.uk
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