Synonyms: exertional thrombosis, effort thrombosis, venous type thoracic outlet obstruction.
Criteria for diagnosis:
(1) presence of thrombosis in the axillary and/or subclavian vein, more often on the right side
(2) exclusion of causes for secondary thrombosis
(3) compatible history
(4) demonstration of venous compression
Conditions associated with secondary thrombosis:
(1) direct trauma
(2) catheter-related
(3) intravenous drug use
(4) primary or secondary hypercoagulable state (some include, some exclude)
Preceding History:
(1) vigorous physical exertion of the upper extremity, often repetitive (typically an athlete or worker using the upper extremity)
(2) occasionally thrombosis may occur spontaneously in a young or middle aged person, without preceding event
(3) elderly patients with comorbid conditions and a secondary hypercoagulable state (such as carcinoma) may develop the venous thrombosis spontaneously, without exertion
Etiology of venous compression:
(1) compression of the subclavian vein between the first rib posteriorly and the clavicular head anteriorly.
(2) presence of abnormal soft tissue mass
(3) muscle hypertrophy (anterior scalene, subclavian muscles)
(4) fibrous bands
(5) scar after clavicular fracture
Compression of the subclavian vein may become evident during lateral abduction of the arm.
Imaging studies (Machleder, 1993):
(1) venography
(2) Doppler ultrasonography (can demonstrate thrombosis but may be inaccurate for venous assessment in the retroclavicular space)
(3) MRI (can demonstrate thrombosis but may be inaccurate for venous assessment in the retroclavicular space)
Management:
(1) thrombolysis with short term anticoagulation
(2) acute thrombectomy
(3) balloon angioplasty
(4) stent placement
(5) resection of the first rib
(6) jugular-subclavian bypass grafting if subclavian vein damaged
Indications for surgical management – one of the following:
(1) residual stenosis or compression after restoration of vein patency
(2) obstruction of venous drainage with abduction of the arm
(3) stent failure
