Radionuclide venography in subclavian vein thrombosis complicating parenteral nutrition

Subclavian vein thrombosis and thrombophlebitis are common complications of subclavian vein catheterization for parenteral nutrition. We report two cases that demonstrate that radionuclide venography can be used to diagnose subclavian vein obstruction before classic clinical signs develop.     

Percutaneous interventions in subclavian artery-to-contralateral subclavian vein "necklace" hemodialysis grafts: experience in five patients

PURPOSE: To describe clinical outcomes of endovascular interventions in the setting of thrombosis or dysfunction of anterior chest wall ("necklace") arteriovenous (AV) hemodialysis grafts. MATERIALS AND METHODS: Eight percutaneous interventions (balloon angioplasty, pharmacologic thrombolysis, and mechanical thrombectomy) were performed in five patients with anterior chest wall AV grafts. Primary, assisted, and secondary patencies, as well as technical success and complication rates, were determined. RESULTS: The technical success rate of percutaneous interventions in re-establishing a normal blood flow pattern within the AV grafts was 100%. Primary patency ranged from one to 23 months (median, 5 months). Primary assisted patency and secondary patency were 36 months and 8 months, respectively, in two patients who underwent more than one intervention. Postintervention access patency ranged from 5 to 36 months (median, 9 months), whereas graft lifetime ranged from 12 to 45 months (median, 24 months). There were no complications related to revascularization procedures. CONCLUSION: Percutaneous interventions can be performed safely and effectively in anterior chest wall AV grafts. Technical success and long-term patency rates appear to be similar to those of percutaneous interventions in upper-extremity hemodialysis AV grafts.     

Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis

The primary imaging technique in suspected venous occlusive disease has for many years been contrast venography. Recent studies have shown ultrasound with the addition of colour Doppler imaging to be a suitable alternative method in the diagnosis of lower limb venous thrombosis. We have applied these techniques to the upper limb venous system, and have performed a prospective study of 19 patients (30 limbs) comparing colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis, for which colour Doppler ultrasound has a sensitivity and specificity of 100%. If vein stenosis is included, the sensitivity falls to 89%. We propose that colour Doppler ultrasound is a suitable first-line alternative to venography in the diagnosis of axillary and subclavian vein thrombosis. In addition to showing the major venous drainage of the upper limb, ultrasound routinely assesses patency of the internal jugular vein, which is, on occasion, of clinical relevance when determining possible future sites of venous access. If, however, colour Doppler ultrasound is normal then bilateral upper limb venography is indicated to exclude a more central venous problem or localized stenotic lesion.     

Effort thrombosis in the elite throwing athlete

BACKGROUND: Upper extremity vascular injuries are uncommon in the elite throwing athlete. However, the extreme stresses that are placed on the upper extremity of elite baseball players, especially pitchers, puts them at risk for such injuries. One such injury is upper extremity venous thrombosis or "effort thrombosis." PURPOSE: We wanted to review the common initial clinical symptoms and physical examination findings of effort thrombosis in elite baseball players and to review the associated clinical conditions such as hypercoagulable states and pulmonary embolism. STUDY DESIGN: Retrospective review of a series of cases. METHODS: A retrospective review of the medical records of a Major League Baseball organization and a Division I college was performed for the period 1987 to 1997. RESULTS: We located four cases of effort thrombosis involving elite baseball players. Contrast venography was used to confirm the diagnosis in all cases. All patients were successfully treated with transluminal catheter-directed urokinase thrombolysis followed by first rib resection and systemic anticoagulant therapy for up to 3 months. All four players returned to play at or above their previous level of competition with no long-term chronic sequelae. CONCLUSIONS: Prompt clinical recognition, diagnosis, and treatment of effort thrombosis in the elite baseball player provides the player with an excellent prognosis for return to the previous level of play.     

Asymptomatic aneurysm of the subclavian vein

Venous aneurysms are rare entities whose etiology remains unknown. We report an incidental observation of an asymptomatic, saccular aneurysm of the subclavian vein and discuss the possible origin and clinical impact, with special remarks on venous interventions.     

Scintigraphic assessment of "effort" axillary-subclavian vein thrombosis.

"Effort" axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) is an uncommon deep venous thrombosis due to repetitive activity of the upper limb. Clinical suspicion is usually confirmed by contrast venography. This report describes a case where the diagnosis was made by radionuclide venography (Tc-99m DTPA). The examination was carried out in the acute phase and clearly demonstrated the presence and the site of the obstruction as well as the collateral vessels. Despite a complete clinical recovery, obtained by medical therapy, further examinations performed in the follow-up period showed persistence of the thrombotic obstruction and a rich development of collateral vessels. In the authors' opinion, radionuclide venography is worth considering as a first-choice procedure when an axillary-subclavian vein thrombosis is suspected, and contrast venography should be performed only when surgical treatment is indicated.     

Local thrombolytic therapy for subclavian and axillary vein thrombosis. Treatment of the thoracic inlet syndrome

Four patients with primary subclavian-axillary vein thrombosis are described. Each patient received local thrombolytic therapy, resulting in reestablishment of antegrade flow via the axillary and subclavian veins. An intrinsic venous abnormality (perimural fibrosis and/or intimal dissection) identified at the first rib-clavicle junction (subclavian-axillary vein junction) was thought to be responsible for the thrombosis. One of the four patients subsequently underwent a surgical venous bypass of the abnormal segment, and a second underwent percutaneous transluminal angioplasty.     

Effort thrombosis of the upper extremity in a young sportsman: Paget-Schroetter syndrome

Paget-Schroetter syndrome is the spontaneous thrombosis of the axillary/subclavian vein. A 16-year-old male presented with acute onset of right upper limb swelling after vigorous weight training. A venogram confirmed the diagnosis of Paget-Schroetter syndrome. He was started on intravenous thrombolytics followed by oral anticoagulation therapy. His symptoms resolved and he was symptom free at six-month follow-up. Thrombolytics and anticoagulation is the most widely accepted first-line therapy for this syndrome. Defining any anatomical anomaly as the predisposing factor in this condition is essential in the selection of which patients will benefit from thoracic outlet decompression.     

Superior vena cava syndrome and bilateral subclavian vein thrombosis. CT and radionuclide venography correlation

Radionuclide venography (RNV) and CT with contrast infusion were performed in a patient with superior vena cava (SVC) syndrome and upper extremity swelling due to SVC and bilateral subclavian vein thrombosis resulting from infection of a Le Veen peritoneovenous shunt. Although CT was suggestive of thrombosis and excluded extrinsic compression by a mass, obstruction of the SVC and deliniation of collateral venous channels were best demonstrated by RNV.     

Thrombolytic therapy in catheter-related subclavian venous thrombosis

A 57-year-old woman presented with swelling of her left arm. She had had an indwelling Hickman infusion catheter for five months. Venography demonstrated subclavian vein thrombosis which was successfully treated using a low-dose streptokinase infusion into the involved catheter over a 20-hour period. No complications related to embolic disease were observed during the treatment period or during six months of follow-up.     

Effort thrombosis: Role of interventional therapy

Effort thrombosis, a form of axillary-subclavian vein occlusion in young people, was identified in patients referred over a 5-year period. Eleven of 120 patients (9%) with venous occlusion from many causes had effort thrombosis. They were treated acutely with heparin and then by thrombolysis, angioplasty, surgical bypass, or a combination. Five of the 10 patients with thrombolysis or surgery had patent veins on follow-up venography, but 9 of these later developed axillary-subclavian reocclusion. By later follow-up, however, all patients were asymptomatic at the time of collateral vein formation. We conclude that effort thrombosis leads to recurrent occlusion of the axillary-subclavian vein, short-term (12-month) recurrence of symptoms with exercise, and progressive compensatory collateral vein development. Radiographic documentation of reestablished venous flow is important, and can be used to guide the completion of treatment.