Upper limb DVT

Posted by e-Medical PPT Saturday, October 9, 2010
Spontaneous subclavian or axillary vein thrombosis (Paget-Schröetter syndrome) comprises 2% of all DVTs.Whereas age and immobility are risk factors for lower limb DVT, upper limb DVT occurs in young, active patients. The mechanism is thought to be extrinsic compression of the subclavian vein within a tunnel comprising the first rib inferiorly, the subclavius muscle superiorly, the costoclavicular ligament medially and the anterior scalene muscle laterally. Abnormalities such as a laterally inserting costoclavicular ligament or cervical rib (10%) can compress the subclavian vein, predisposing to thrombosis.Complications include post-phlebitic limb syndrome from resultant valvular incompetence, venous gangrene and pulmonary embolism.

Compressive vascular signs may be elicited with the following stress tests:
• The rowing maneuver: loss of the radial pulse as the shoulders are braced backwards. This is an alternative to Adson’s test, where the head is turned away from the affected limb and a deep inspiration results in loss of the affected radial pulse. Both of these signs have an appreciable false-positive rate.
• Pemberton’s maneuver: the arms are elevated and facial plethora with distended neck veins are seen due to impeded venous return. This test is positive if the thrombus extends into the brachiocephalic vein.

In patients with spontaneous upper limb DVT, treatment strategies include anticoagulation, thrombolysis, venoplasty and surgical decompression. Consensus statements advocate catheter-directed thrombolysis within 5 days of symptoms. This may reveal underlying stenosis. However, balloon venoplasty and stenting are recognized to render poor results unless the extrinsic compression is surgically corrected.Hence, if there is evidence of thoracic outlet compression on imaging or symptomatic venous stenosis, consensus opinion advocates thoracic outlet decompression.

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