Thoracic Outlet Syndrome: An unheard of cause of arm DVT

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This week, top ranked American and Olympic gold medalist golfer Nelly Korda, 23, was diagnosed with a blood clot, or deep vein thrombosis (DVT), in her arm. More commonly, we hear about DVT in the leg which can sometimes lead to a more devastating clot in the lung known as a pulmonary embolism (PE). What causes an arm DVT and is it treated the same as a leg DVT? Are the long term complications of an arm DVT similar to a leg DVT?

In comparison to the leg, DVT of the arm is not as common. In the hospital setting, arm DVT tends to be associated with central venous catheters such as a dialysis catheter or peripherally inserted central catheter known as a PICC line. In the outpatient setting, the most common cause of arm DVT is thoracic outlet syndrome (TOS).

Thoracic Outlet Syndrome (TOS)

TOS is a group of disorders in which the artery, vein, and/or nerve get compressed between the clavicle (collarbone) and the first rib — an area known as the thoracic outlet.

Fig 1. Thoracic outlet
Types of TOS

Arterial (2-5% of TOS cases) — subclavian artery compressed, leading to blockage or aneurysm formation in the artery as well as blood clots in the hands/fingers. This is the least common type of TOS.

Venous (10-15% of TOS cases) — subclavian vein compressed, leading to arm swelling and blood clots. Patients can also have bluish discoloration of the arm along with heaviness and pain. Venous TOS is also referred to as Paget-Schroetter syndrome or “effort thrombosis” since it is seen in those doing a lot of strenuous activity with the arm.

Neurogenic (85-95% of TOS cases) — brachial plexus nerve roots are compressed leading to chronic pain, numbness, tingling. Symptoms can worsen when the arm is lifted above the head.

TOS Diagnosis and Treatment

The diagnosis of TOS is often made by a vascular specialist. A thorough history and physical exam is important as treatment of TOS varies depending on the type. If a patient has developed a DVT like Ms. Korda, a blood thinner is often prescribed. In severe cases, extensive DVT can be removed using minimally invasive techniques. However, neither of these treatments treat the underlying cause of the DVT which is the compression of the vein in the thoracic outlet.

Unlike other types of vascular compression such as May Thurner Syndrome that is treated with a stent, a stent cannot be placed in the thoracic outlet due to the risk of stent fracture. Therefore, surgical removal of the first rib is often needed to “open up” the thoracic outlet and make more space for the blood vessels and nerves. This procedure is generally done by a vascular surgeon and in some cases, a neurosurgeon.

Conservative treatment of TOS may include physical therapy. Botox injections have also been done to prevent spasm of the scalene muscles in the thoracic outlet resulting in relief of nerve pain.

Complications of Arm DVT

Like the leg, post-thrombotic syndrome (PTS) can affect the arm leading to chronic pain, swelling, heaviness, and fatigue. PTS can be challenging to treat, and there is no cure. Minimally invasive procedures such as deep vein recanalization (DVR) can be performed in experienced centers for PTS in the leg. In the arm, however, PTS is harder to treat since stents cannot often be used or have poor patency (ability to stay open).

DVT in Professional Athletes

Ms. Norda is not alone. While we don’t know the exact cause of her DVT, other athletes such as tennis superstar Serena Williams, NBA player Chris Bosh, and racecar driver Brian Vickers have themselves been affected by DVT and/or PE. The key to successful treatment in all of these cases is early recognition of symptoms and expedited medical care. DVT and PE together are known as venous thromboembolism or VTE which is the 3rd most common cause of cardiovascular death behind heart attack and stroke. Knowing the symptoms of VTE can save your life or that of someone you love.

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1 Comment

  1. Carol Derstine

    I have MTS and have Chronic Thrombosis . I have found the best way to keep circulation is to keep moving and active.

    Reply

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