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Primary thrombosis of the axillary vein
PRIMARY THROMBOSIS OF THE AXILLARY VEIN B. V.
MCCLANAHAN,
M.D.
GALESBURG, ILL.
S
OME four months after the appearance of an articIe by Dr. Rudolph Matas entitIed “Primary Thrombosis of the AxiIIary Vein caused by Strain,” which wiII be often quoted in this paper, I had the fortune to see such a case five days after the onset, and to foIIow it cIoseIy for two and one-haIf months. Interest in this case has prompted this paper. Venous thrombosis, whiIe quite common in peIvic and Iower extremity veins, is a comparative rarity in veins of the upper extremity. Even more rare is a thrombosis from effort (so-caIIed effort resulting thrombosis) or as it has been termed by English writers “idiopathic” thrombosis. The causative factors of such a condition are not cIearIy understood, but a11 are based on the factor of slowing or stagnation of the venous bIood stream. Infection, whiIe no doubt often a causative factor in Iower extremity thrombosis, is according to Matas untenabIe when applied to a study of this type of vascuIar disease. Syphilis, though often mentioned and suggested as a causative factor, is stated by Lowenstein2 to be “as rare as syphiIitic arteritis is common, a point emphasized by WeIch years ago.” It is doubtfu1 that simpIe injury to a vein or its intima may cause such a condition, otherwise more serious compIications wouId arise in the course of intravenous therapy and administration which is so widely practiced today. Matas discusses at Iength the sympathetic theory as Iaid down by CattaIorda of MarseiIIes, stating that:
irritation of an inflamed or injured perivenous pIexus in the venous waII that is responsible for the rapid edematous sweIIing. It is on this basis that CattaIorda expIains the reIief obtained by excision of the injured venous segment that he and others have obtained by this procedure in cases of axiIIary thrombosis by strain.
Even though WiIson3 reports a case of a patient who, with no previous symptoms, awoke to find the arm swoIIen and painful, practicaIIy a11 of the cases, as the one reported here, immediateIy foIIow effort. Lowenstein’s concIusion, based on extensive anatomical dissection, is that thrombosis of the axiIIary vein at the junction of the cephaIic is provoked in certain cases by partia1 constriction by the costocoroid ligament and the subclavius muscle. With the arm extended the costocoroid Iigament and subcIavius muscIe are put on a stretch, and the sharp firm Iower border exerts considerabIe pressure at the superior surface of the axiIIary vein. Abduction of the arm increases this condition as does the puI1 of the pectoralis minor muscIe, while ffexion reIaxes it. A vaIve in the axiIIary vein at the junction of the cephaIic also may be ruptured. MaIes predominate in this condition,4 which occurs in robust young individuaIs usuahy between twenty to forty years of age; no case has ever been reported in which the patient was under ten years of age. The right arm is usuaIIy affected, unIess the individua1 is Ieft handed. PeIIot5 reports this condition obtains in g out of I0 cases. Diagnostic points in weII-deveIoped cases as mentioned by Matas,l Horton6 and Veno-spasm pIays a part. . . . The mere others are that the affected arm is heId obstruction of the Iumen is not only the onIy out from the side or the forearm Aexed’ in cause of the edema, but it is the persistent 459
460
American Journal of Surgery
McCIanahan-Thrombosis
a non-dependent position, there is a characteristic firm doughy edematous sweIling of the affected extremity foIIowing an accident or strain, a sense of discomfort, fuIIness after exercise, varying degrees of cyanosis, diIation of the superficiar veins of the upper arm and pectora1 region of the chest on the affected side. Motion is not Iimited, but is voluntariIy restricted. The bIood pressure, which one wouId expect to be raised on the affected side, may even be norma or Iower than when taken in the opposite arm. Roentgenograms are usuaIIy negative. A firm sensitive cord-Iike area corresponding to the axiIIary vein is universaIIy
found.
On the morning of October IO, 1934, I was caIIed by phone from the farm home of this patient and given the foIlowing history: In the morning of the day before while pitching soy beans he had noticed a sudden severe pain at the inner side of the right arm, which pain seemed to extend up the arm to the upper part of the right chest, and that with this pain he noticed a peculiar numbness of the affected arm and hand. He stopped work for a few moments, holding the arm up, as this position was the most comfortabIe. The pain grew Iess and he resumed his work. He soon had to quit however, went into the house and rested, with the right arm eIevated, which again gave him reIief. After dinner he tried to resume his work, but in a very short time the arm was aching and seemed so heavy that he was forced to quit for the day. I advised, by phone, that the arm be rested, eIevated and dry heat be applied if comfortabre. Five days Iater the patient (G. L.), a muscuIar aduIt, seventeen years of age, 4 feet IO inches taI1, weighing 162 pounds, and appearing in vigorous heaIth, came into my office supporting his fIexed right forearm with his Ieft hand. He reiterated the history and also stated that foIIowing two days’ rest he had gone out to pick some corn onIy to find a recurrence of his former symptoms. He was forced again to quit this work, and now foIIowing another two days’ rest came in to find out about the condition. He stated that rest and eIevation relieved, but that appIication of heat aggravated the condition. Past history eIicited measIes, whooping
DECEMBER,
1935
cough and chicken pox in chiIdhood. There was no history of diseases apt to affect the vascular system as typhoid, rheumatism, septicemia, endocarditis, gout, chronic Iead poisoning or any foca1 infection. Appendectomy was performed in I 93 I foIIowing his first attack of acute appendicitis, with uneventful recovery. He had been in exceIIent hearth, and had been accustomed to doing heavy muscuIar work, trucking, harvesting, etc. FamiIy history was essentiaIIy negative and both parents were aIive and well. PhysicaI examination was for the most part normaI, with the exception of the upper right extremity. His tonsils were smaI1 and appeared normaI. Teeth were in exceIIent condition. There was no cervica1 or genera1 adenopathy. I was unabIe to find or elicit a hjstory of hernias or other developmental defects. Examination of his right arm reveaIed a tender area corresponding to the venous channe1 in the axiIIa and tenderness on pressure upwards toward the cIavicIe. There were no paIpabIe gIands either in the axiIIary or supratrochlear areas. There was a fuIIness noticeabIe in the anterior shouIder and pectoraIis regions (which areas on subsequent examinations reveaIed the presence of diIated superficia1 veins as coIIatera1 circuIation became more marked). BIood pressure readings taken at the origina examination were: right arm I&$/TO; Ieft arm 122/70; and taken two months Iater were: right arm 126/70; Ieft arm 122/70. Measurements taken within ten days of the onset, and again two months Iater are shown in Table I. TABLE October
17,
I
1934
December
ao,
1934
Right
Above biceps. Bicepsregion. Belowbiceps. Midforearm. Wrist,
.
x2.5 (31.5) 12.0 (30.0) 12.0 (30.0) 11.75(29.5) 7.5
(19.0)
II (27.5) 11.5 (28.5) 11.75 (29.5) II.ZS(Z~.O) 7.5
(19.0)
14.SC36.5) 13.oC32.5) 12.5 (31.5) rz.o(30.0) 8.oC20.5)
11 (27.5) 10.5C27.0) 11.5 (28.5) 11.0(27.5) 7.5
(19.0)
UrinaIysis was negative as to findings. The bIood count, with the exception of a sIight Ieucocytosis, was normaI; reds 4,g5o,ooo; whites I 1,700; hemogIobin go per cent; differentia1 poIymorphonucIears 70 per cent; smaI1 Iymphocytes 21 per cent; Iarge mononucIear 8 per cent; eosinophiIes I, basophiIes o. Coagu-
NEW SERIES VOL.XXX, No. 3
McCIanahan-Thrombosis
Iation time 4.15. Both Wassermann and Kahn reactions were negative. As this patient was staying with reIatives, having come from his home in Kansas seeking work, I was unable to persuade him to remain here Ionger and he returned to his home for the hohdays. During the period he was under my care he repeatedIy tried different sorts of work, but couId foIIow none for more than a very short time, and the more vigorous the task the sooner he was forced to stop. At the time of his departure he was developing a we&marked coIIatera1 circuIation over the anterior shouIder and pectora1 region. The painful area in the axiIIa corresponding to the course of the vesseIs became somewhat Iess tender, but persisted. No medication was given at any time, and he refused to have the arm or hand bound up, preferring to carry the arm flexed, when it was most painfu1. A recent communication from him late in February of this year states that the arm is Iarger than when he Ieft my observation, and he has about given up the idea of trying to do any sort of physica labor. Further, that he has not done anything further regarding treatment due to compIete Iack of funds. To me this case has been of especial interest because I was personally able to observe this comparativeIy rare condition virtually from its onset. The history and early progress of the case are cIassica1. I was unabIe to convince him early of the severity of the condition, for when he was idle and carefu1 he was quite comfortable. He no doubt is already convinced of a change that must necessarily occur for a11 these individuaIs, i.e. a change from a life of manua1 physica labor to one of a passive sedentary roIe. Horton in 1931 reported a similar case. The usual consuIting of several physicians and the genera1 minimizing of severity of prognosis foIIowed, with no definite diagnosis having been made unti1 he saw the case some time later. He states that the prognosis in cases of this type seems to be uniformIy good. Other authors, however,
American
Journal
of Surgery
461
are optimistic onIy in very earIy and very mild cases. AIso due to the time necessary to effect improvement these cases are of especial interest from an industrial and insurance standpoint. It would appear that if such cases when mild could be diagnosed early, the patient appraised of the severity of the condition, properly handled and cared for until an adequate colIatera1 circulation became established, they might be saved a great deaI of discomfort. One thing is certain from a standpoint of treatment and that is, that sureIy a change to a sedentary occupation is necessary and shouId be earliest possible accomplished at the opportunity. SUMMARY
The comparative rarity of this disease mitigates against its earIy detection and should again emphasize the need of compIete histories and physica examinations. The ultimate gravity of this condition should not be overlooked. Even though of miId onset the patient shouId at once stop active physical work, either permanently, or until an adequate efficient coIIatera1 circuIation is estabIished. This may take months to deveIop and during this period no work or exercise that causes swelIing or pain in the arm should be permitted. In this way it may be possible to save these individuaIs much time in recovery and to give them a better expectation as to fina resuIts. REFERENCES I.
MATAS, R., AM. J. SURG., n.s. 24: 642-666
2.
1934. LOWENSTEIN,P. S. J. A. M. A., 82: 854-857 (Mar.)
(June)
1924.
3. WILSON, G. Am. J. M. SC., 163: 8gg (June) 1922. 4. GOULD, E. P., and PATEY, H. D. Brit. J. Surg., 16:
208-212 (Oct.) 1928.
5. PELLOT.Presse mCd., 24: 523, 1916. 6. HORTON, B. T. J. A. M. A., 96: zrg4-2196 193’.
(July)
MCCLANAHAN,
M.D.
GALESBURG, ILL.
S
OME four months after the appearance of an articIe by Dr. Rudolph Matas entitIed “Primary Thrombosis of the AxiIIary Vein caused by Strain,” which wiII be often quoted in this paper, I had the fortune to see such a case five days after the onset, and to foIIow it cIoseIy for two and one-haIf months. Interest in this case has prompted this paper. Venous thrombosis, whiIe quite common in peIvic and Iower extremity veins, is a comparative rarity in veins of the upper extremity. Even more rare is a thrombosis from effort (so-caIIed effort resulting thrombosis) or as it has been termed by English writers “idiopathic” thrombosis. The causative factors of such a condition are not cIearIy understood, but a11 are based on the factor of slowing or stagnation of the venous bIood stream. Infection, whiIe no doubt often a causative factor in Iower extremity thrombosis, is according to Matas untenabIe when applied to a study of this type of vascuIar disease. Syphilis, though often mentioned and suggested as a causative factor, is stated by Lowenstein2 to be “as rare as syphiIitic arteritis is common, a point emphasized by WeIch years ago.” It is doubtfu1 that simpIe injury to a vein or its intima may cause such a condition, otherwise more serious compIications wouId arise in the course of intravenous therapy and administration which is so widely practiced today. Matas discusses at Iength the sympathetic theory as Iaid down by CattaIorda of MarseiIIes, stating that:
irritation of an inflamed or injured perivenous pIexus in the venous waII that is responsible for the rapid edematous sweIIing. It is on this basis that CattaIorda expIains the reIief obtained by excision of the injured venous segment that he and others have obtained by this procedure in cases of axiIIary thrombosis by strain.
Even though WiIson3 reports a case of a patient who, with no previous symptoms, awoke to find the arm swoIIen and painful, practicaIIy a11 of the cases, as the one reported here, immediateIy foIIow effort. Lowenstein’s concIusion, based on extensive anatomical dissection, is that thrombosis of the axiIIary vein at the junction of the cephaIic is provoked in certain cases by partia1 constriction by the costocoroid ligament and the subclavius muscle. With the arm extended the costocoroid Iigament and subcIavius muscIe are put on a stretch, and the sharp firm Iower border exerts considerabIe pressure at the superior surface of the axiIIary vein. Abduction of the arm increases this condition as does the puI1 of the pectoralis minor muscIe, while ffexion reIaxes it. A vaIve in the axiIIary vein at the junction of the cephaIic also may be ruptured. MaIes predominate in this condition,4 which occurs in robust young individuaIs usuahy between twenty to forty years of age; no case has ever been reported in which the patient was under ten years of age. The right arm is usuaIIy affected, unIess the individua1 is Ieft handed. PeIIot5 reports this condition obtains in g out of I0 cases. Diagnostic points in weII-deveIoped cases as mentioned by Matas,l Horton6 and Veno-spasm pIays a part. . . . The mere others are that the affected arm is heId obstruction of the Iumen is not only the onIy out from the side or the forearm Aexed’ in cause of the edema, but it is the persistent 459
460
American Journal of Surgery
McCIanahan-Thrombosis
a non-dependent position, there is a characteristic firm doughy edematous sweIling of the affected extremity foIIowing an accident or strain, a sense of discomfort, fuIIness after exercise, varying degrees of cyanosis, diIation of the superficiar veins of the upper arm and pectora1 region of the chest on the affected side. Motion is not Iimited, but is voluntariIy restricted. The bIood pressure, which one wouId expect to be raised on the affected side, may even be norma or Iower than when taken in the opposite arm. Roentgenograms are usuaIIy negative. A firm sensitive cord-Iike area corresponding to the axiIIary vein is universaIIy
found.
On the morning of October IO, 1934, I was caIIed by phone from the farm home of this patient and given the foIlowing history: In the morning of the day before while pitching soy beans he had noticed a sudden severe pain at the inner side of the right arm, which pain seemed to extend up the arm to the upper part of the right chest, and that with this pain he noticed a peculiar numbness of the affected arm and hand. He stopped work for a few moments, holding the arm up, as this position was the most comfortabIe. The pain grew Iess and he resumed his work. He soon had to quit however, went into the house and rested, with the right arm eIevated, which again gave him reIief. After dinner he tried to resume his work, but in a very short time the arm was aching and seemed so heavy that he was forced to quit for the day. I advised, by phone, that the arm be rested, eIevated and dry heat be applied if comfortabre. Five days Iater the patient (G. L.), a muscuIar aduIt, seventeen years of age, 4 feet IO inches taI1, weighing 162 pounds, and appearing in vigorous heaIth, came into my office supporting his fIexed right forearm with his Ieft hand. He reiterated the history and also stated that foIIowing two days’ rest he had gone out to pick some corn onIy to find a recurrence of his former symptoms. He was forced again to quit this work, and now foIIowing another two days’ rest came in to find out about the condition. He stated that rest and eIevation relieved, but that appIication of heat aggravated the condition. Past history eIicited measIes, whooping
DECEMBER,
1935
cough and chicken pox in chiIdhood. There was no history of diseases apt to affect the vascular system as typhoid, rheumatism, septicemia, endocarditis, gout, chronic Iead poisoning or any foca1 infection. Appendectomy was performed in I 93 I foIIowing his first attack of acute appendicitis, with uneventful recovery. He had been in exceIIent hearth, and had been accustomed to doing heavy muscuIar work, trucking, harvesting, etc. FamiIy history was essentiaIIy negative and both parents were aIive and well. PhysicaI examination was for the most part normaI, with the exception of the upper right extremity. His tonsils were smaI1 and appeared normaI. Teeth were in exceIIent condition. There was no cervica1 or genera1 adenopathy. I was unabIe to find or elicit a hjstory of hernias or other developmental defects. Examination of his right arm reveaIed a tender area corresponding to the venous channe1 in the axiIIa and tenderness on pressure upwards toward the cIavicIe. There were no paIpabIe gIands either in the axiIIary or supratrochlear areas. There was a fuIIness noticeabIe in the anterior shouIder and pectoraIis regions (which areas on subsequent examinations reveaIed the presence of diIated superficia1 veins as coIIatera1 circuIation became more marked). BIood pressure readings taken at the origina examination were: right arm I&$/TO; Ieft arm 122/70; and taken two months Iater were: right arm 126/70; Ieft arm 122/70. Measurements taken within ten days of the onset, and again two months Iater are shown in Table I. TABLE October
17,
I
1934
December
ao,
1934
Right
Above biceps. Bicepsregion. Belowbiceps. Midforearm. Wrist,
.
x2.5 (31.5) 12.0 (30.0) 12.0 (30.0) 11.75(29.5) 7.5
(19.0)
II (27.5) 11.5 (28.5) 11.75 (29.5) II.ZS(Z~.O) 7.5
(19.0)
14.SC36.5) 13.oC32.5) 12.5 (31.5) rz.o(30.0) 8.oC20.5)
11 (27.5) 10.5C27.0) 11.5 (28.5) 11.0(27.5) 7.5
(19.0)
UrinaIysis was negative as to findings. The bIood count, with the exception of a sIight Ieucocytosis, was normaI; reds 4,g5o,ooo; whites I 1,700; hemogIobin go per cent; differentia1 poIymorphonucIears 70 per cent; smaI1 Iymphocytes 21 per cent; Iarge mononucIear 8 per cent; eosinophiIes I, basophiIes o. Coagu-
NEW SERIES VOL.XXX, No. 3
McCIanahan-Thrombosis
Iation time 4.15. Both Wassermann and Kahn reactions were negative. As this patient was staying with reIatives, having come from his home in Kansas seeking work, I was unable to persuade him to remain here Ionger and he returned to his home for the hohdays. During the period he was under my care he repeatedIy tried different sorts of work, but couId foIIow none for more than a very short time, and the more vigorous the task the sooner he was forced to stop. At the time of his departure he was developing a we&marked coIIatera1 circuIation over the anterior shouIder and pectora1 region. The painful area in the axiIIa corresponding to the course of the vesseIs became somewhat Iess tender, but persisted. No medication was given at any time, and he refused to have the arm or hand bound up, preferring to carry the arm flexed, when it was most painfu1. A recent communication from him late in February of this year states that the arm is Iarger than when he Ieft my observation, and he has about given up the idea of trying to do any sort of physica labor. Further, that he has not done anything further regarding treatment due to compIete Iack of funds. To me this case has been of especial interest because I was personally able to observe this comparativeIy rare condition virtually from its onset. The history and early progress of the case are cIassica1. I was unabIe to convince him early of the severity of the condition, for when he was idle and carefu1 he was quite comfortable. He no doubt is already convinced of a change that must necessarily occur for a11 these individuaIs, i.e. a change from a life of manua1 physica labor to one of a passive sedentary roIe. Horton in 1931 reported a similar case. The usual consuIting of several physicians and the genera1 minimizing of severity of prognosis foIIowed, with no definite diagnosis having been made unti1 he saw the case some time later. He states that the prognosis in cases of this type seems to be uniformIy good. Other authors, however,
American
Journal
of Surgery
461
are optimistic onIy in very earIy and very mild cases. AIso due to the time necessary to effect improvement these cases are of especial interest from an industrial and insurance standpoint. It would appear that if such cases when mild could be diagnosed early, the patient appraised of the severity of the condition, properly handled and cared for until an adequate colIatera1 circulation became established, they might be saved a great deaI of discomfort. One thing is certain from a standpoint of treatment and that is, that sureIy a change to a sedentary occupation is necessary and shouId be earliest possible accomplished at the opportunity. SUMMARY
The comparative rarity of this disease mitigates against its earIy detection and should again emphasize the need of compIete histories and physica examinations. The ultimate gravity of this condition should not be overlooked. Even though of miId onset the patient shouId at once stop active physical work, either permanently, or until an adequate efficient coIIatera1 circuIation is estabIished. This may take months to deveIop and during this period no work or exercise that causes swelIing or pain in the arm should be permitted. In this way it may be possible to save these individuaIs much time in recovery and to give them a better expectation as to fina resuIts. REFERENCES I.
MATAS, R., AM. J. SURG., n.s. 24: 642-666
2.
1934. LOWENSTEIN,P. S. J. A. M. A., 82: 854-857 (Mar.)
(June)
1924.
3. WILSON, G. Am. J. M. SC., 163: 8gg (June) 1922. 4. GOULD, E. P., and PATEY, H. D. Brit. J. Surg., 16:
208-212 (Oct.) 1928.
5. PELLOT.Presse mCd., 24: 523, 1916. 6. HORTON, B. T. J. A. M. A., 96: zrg4-2196 193’.
(July)