Though up to 90 percent of all DVTs occur in the lower extremities, a clot can develop in the axillary or subclavian vein. The risk factors for developing a venous thrombus in the upper extremity are like those outlined in T.a.ble 5.5-1 and Table. ..55r2., a higher incidence being associated with venous catheterization, intravenous drugs, excessive or unusual exercise (effort thrombosis), malignancy, and other hypercoagulable states. A predisposing venous stricture or chronic compression (cervical rib, hypertrophied scalene muscle, congenital web, etc.) is not uncommonly detected as a causal factor. The patient with DVT of an upper extremity can present with an abrupt or gradual onset of swelling in the arm, associated with dilated veins in the hand and forearm. The arm may feel heavy, with pain on physical activity which is relieved with rest. Sudden onset of severe pain and swelling with a change in the color of the arm is a rare presentation. The two primary methods of investigating a suspected venous thrombosis of an upper limb is by duplex ultrasound or venography. Computed tomography (CT) and MRI are occasionally useful in difficult cases.
It is estimated that a PE occurs in 10 to 30 percent of cases involving axillary or subclavian DVT; aggressive therapy is warranted in such instances. Current treatment options include anticoagulation alone or preceded by catheter-directed thrombolysis. The choice of therapy should be discussed with the consulting vascular surgeon and invasive radiologist but should be individualized in every case. The underlying cause, duration of symptoms, comorbidity and contraindications to lytic agents or anticoagulants can help guide the choice of the most appropriate therapy. Resolution of symptoms and signs is dependent not only on therapy but also on the development of collateral flow. Following initial therapy, an underlying compressive abnormality or venous stenosis, if present, must be corrected (e.g., rib resection, balloon angioplasty).
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