Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 2, 2003, pp. 195-197

Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 195-197

Case Report

Axillary venous thrombosis following hyperabduction of shoulder

K. V. Shanmugha Das, Ajo K. John and S. Vaidyanathan

Department of Surgery, Medical College Hospital, Kottayam 686 008.
Address for correspondence: Prof. S. Vaidyananthan, Department of Surgery, Medical College Hospital, Kottayam 686 008.

Paper Received: June 2001, Paper Accepted: November 2001. Source of Support: Nil

Code Number: is03039

ABSTRACT

We report a case of axillary venous thrombosis in a 30-year-old-man, sustained after hyperabduction of the shoulder during a fall from height.

KEYWORDS: Thrombosis, axillary, venous, shoulder, hyperabduction

How to cite this article: Das KVS, John A, Vaidyananthan S. Axillary venous thrombosis following hyperabduction of shoulder. Indian J Surg 2003;65:195-7.

INTRODUCTION

Venous thrombosis in the upper limb is relatively rare. The main causes of such thrombosis include anatomical abnormalities in the costoclavicular area, trauma, injuries sustained during central venous catheterization (CVC), use of intravenous drugs, and hypercoagulable states. We describe a case of right axillary venous thrombosis following hyperabduction of the shoulder during a fall from height.

CASE REPORT

A 30-year-old man presented with progressive pain and swelling of the right upper arm of two weeks duration. Some six weeks earlier, he had fallen from a tree when his shoulder had been hyperabducted with considerable force. There was no other contributory medical history. Clinical examination revealed a few dilated veins in the proximal part of the arm, which became more prominent during Valsalva's manoeuvre. The right upper limb showed normal arterial pulses and there was no neurological deficit or bony injury. A venogram showed intraluminal filling defects in the distal part of the axillary vein (Figure 1), diagnostic of thrombosis. Other investigations including x-rays of the right shoulder and chest, computerized tomography of the upper chest, coagulation and haematological profiles were normal. The patient was treated with intravenous heparin for 10 days and then maintained on oral warfarin for 6 weeks. A repeat venogram at the conclusion of the oral anticoagulant therapy (Figure 2) showed complete recanalization of the axillary vein and development of collateral circulation.

DISCUSSION

Venous thrombosis occurring in the upper limb accounts for about 2 per cent of all cases of deep venous thrombosis.¹ It can be primary `effort' thrombosis related to the inherent anatomical structure of the thoracic outlet and axillary region or secondary to trauma, infection, congestive cardiac failure, CVC, neoplasms, septic phlebitis, intravenous drug use and hypercoagulable states.^1-6 Zabroszky reported a case of axillary venous thrombosis following a blunt injury with a fractured clavicle.⁷ A literature search failed to reveal any previous cases of axillary vein thrombosis following hyperabduction of the shoulder.

The clinical presentation of major venous thrombosis in the upper limb usually presents with oedema of the upper limb, prominence of superficial veins and neurological symptoms. The diagnosis is confirmed by either duplex ultrasonography or contrast venography^{1-4, 6-7} A survey of relevant surgical literature indicates that radionuclide venography using 99mTC-DTPA is the investigation of choice for diagnosing axillary-subclavian venous thrombosis, with venography being reserved for only when surgery is contemplated.⁸

The treatment options for axillary venous thrombosis include conservative therapy, anticoagulants, catheter-mediated thrombolysis and surgical intervention to remove the intravascular clot or to revise the anatomy of the abnormal costoclavicular space. Patients with axillary-subclavian venous thrombosis due to intrinsic damage (drug use, CVC, hypercoagulable states) require only anticoagulation therapy whereas those with extrinsic obstruction require correction of the surgical pathology as well.^4-,7,9 An anticoagulation therapy includes heparin for one to two weeks followed by oral warfarin for a period of one week to five years.⁶ There is no consensus on the duration of anticoagulation therapy in individual cases.

In our case as no anatomical abnormality existed in the costoclavicular area, which could have acted as a causative factor for the thrombosis, we believe that the thrombosis may have been initiated due to intimal damage to the axillary vein during the forceful hyperabduction of the shoulder.

REFERENCES

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3. Overstreet DS, Skinner WH, Roy TM. Primary thrombosis in the upper extremity. J Ky Med Assoc 1993;91:54-7.
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5. Harley DP, White RA, Nelson RJ, Mehringer CM. Pulmonary embolism secondary to venous thrombosis of the arm. Am J Surg 1984;147:221-4.
6. Donayre CE, White GH, Mehringer SM, Wilson SE. Pathogenesis determines late morbidity of axillosubclavian vein thrombosis. Am J Surg 1986;152:179-84.
7. Zaborszky A, Barabas A, August A. Late vascular complication after blunt trauma. Acta Chir Hung 1992;33:117-23.
8. Giordano A, Muzi M, Massaro M, Rulli F. Scintigraphic assessment of "effort" axillary-subclavian vein thrombosis. Clin Nucl Med 1992;17:933-5.
9. Aziz S, Straehley CJ, Whelan TJ. Effort-related axillosubclavian vein thrombosis. A new theory of pathogenesis and a plea for direct surgical intervention. Am J Surg 1986;152:57-61.

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