Local thrombolytic therapy for primary axillosubclavian vein thrombosis

A 54-year-old architect was admitted with a one-week history of a painful, swollen right arm. The patient was otherwise healthy with no significant past medical history and, in particular, no antecedent history of venous thromboembolism nor of trauma or heavy use of the limb. On examination, the right arm was grossly swollen, warm and erythematous with visible distension of the collateral veins. Ultrasound examination was performed which demonstrated a thrombus in the right axillary and subclavian veins. Following discussion with radiology and vascular teams it was decided to undertake thrombolysis. Venography confirmed occlusion of the right axillary and subclavian with patency of the brachiocephalic and internal jugular beyond (Figure 1). A straight multisided catheter was used to lace the thrombus with approximately 10 mg tissue plasminogen activator (tPA) followed by an infusion of 0.5 mg/hour along with heparin via a sheath side arm. No immediate side-effects were encountered and the patient was transferred to ITU for monitoring. Follow-up angiography performed the subsequent day demonstrated that recanalization of the arm vessels had taken place and also that there was tight subclavian vein stenosis which required balloon dilatation. A radiograph of the cervical spine showed mild spondylosis but no cervical ribs or elongation to suggest bands. The patient was discharged home with a recommendation of at least six months warfarinization. On review, the patient has experienced no further swelling of the limb which is functionally normal allowing him to continue in his career unimpeded.