Surgical Considerations in the Treatment of Axillary-Subclavian Venous Thrombosis in the Era of COVID-19

Introduction

Axillary-subclavian venous thrombosis can arise in patients with anatomical compression of these structures due to venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome or “effort vein thrombosis.” It accounts for 1-4% of all deep venous thromboses (DVT). ¹ The condition most commonly occurs in young athletic patients who work out with upper extremity exercise on a regular basis. Repetitive compression of the subclavian vein between the clavicle and the first rib leads to damage and scarring of the vein, eventually resulting in thrombosis of the vein. ¹

Patients usually present with swelling and discomfort of the involved arm. On examination, there is evidence of engorged veins over the chest wall. Rarely, patients may present in extremis with a pulmonary embolus with manifestations of the same.

Traditional treatment typically includes anticoagulation with intravenous heparin to reduce clot propagation and preserve patency of collateral venous circulation followed by intervention with catheter directed thrombolysis (CDT) with pharmacologic and/or mechanical thrombolysis (PMT). The goal of these therapies being to reduce clot burden, reestablish venous patency, and reduce associated symptoms. Once venous circulation has been re-established, patients are typically evaluated for thoracic outlet decompression with first rib resection. Recurrent thrombosis and failure of treatment is seen in a significant number of patients without decompression of the thoracic outlet.^2,3

The increased risk of thrombosis both in the venous and arterial systems in patients infected with COVID-19 has probably resulted in a higher incidence of patients presenting with thrombotic syndromes. Increased thrombotic events have been widely observed in our practice in patients with a recent history of COVID-19 in both hospitalized patients and those seen in our outpatient clinics. Reliable data regarding the actual incidence of clinically significant thrombotic events in patients with COVID-19 infection has not been reported. When arterial circulation is involved patient presentations tend to be acute life- or limb-threatening events. However the manifestations on the venous side are usually more muted and subtle. As a result, the patient with venous thrombosis may not seek treatment until the disease process is more advanced. Additionally, there may be reluctance on the patient’s part to interact with the doctor’s office or hospital during the pandemic for fear of infection with COVID-19.

The traditional treatment of axillary-subclavian venous thrombosis is resource intensive due to the need for advanced nursing care and increased utilization of intensive care units for thrombolysis procedures often spanning multiple days, resulting in the high cost of care. Increased resource utilization has proven to be a challenge in the era of COVID-19 with many hospitals prioritizing ICU care and critical care nursing resources for patients with active COVID-19 infection.

We recently encountered this conundrum in the management of 2 young patients with effort-induced upper extremity venous thrombosis and had to adapt to an alternate treatment paradigm which was successful in resolving the immediate clinical problem. In these patients suction thrombectomy was performed without the adjunctive use of lytic therapy with good results, reducing the need for resource utilization in the inpatient setting. We offer this new paradigm to the readership for their consideration in the treatment of axillary-subclavian venous thrombosis, not only in these challenging times, but also in better times when the pandemic has abated. Consent was obtained from the patients to publish this report and IRB approval was not required by our institution due to the small number of cases presented.

Case Reports

A 30-year-old male attorney presented with a 2 week history of left upper extremity swelling and discomfort. He had been confined to home due to infection with COVID-19 two months earlier. The patient’s COVID-19 symptoms were mild and after recovering, he was working out with weights while preparing for his bar exam. On physical examination he was noted to have modest swelling of the left upper extremity with engorged veins across the left upper chest wall. Duplex ultrasound confirmed the presence of axillary-subclavian venous thrombosis.

The next day he underwent left upper extremity venogram which confirmed total occlusion of the axillary and subclavian veins with profuse collaterals around the occlusion (Figure 1). The patient was anti-coagulated with intravenous heparin 100 units per kilogram. The occlusion was then crossed with a 0.035 Glidewire (Terumo Medical Corporation, Somersey, New Jersey) with a support catheter followed by suction thrombectomy using a CAT 8 Indigo catheter from Penumbra (Penumbra Inc. Alameda, California.) Multiple passes of the catheter were necessary before satisfactory clearing of the thrombus burden was achieved (Figure 2). Both acute and chronic thrombus burden were removed from the occluded veins (Figure 3). There was minimal additional blood loss. Balloon angioplasty of the involved veins, particularly the segment at the thoracic outlet, was performed with 12 mm x 4 cm balloon requiring multiple inflations to achieve a good result. The collateral veins previously seen were no longer in evidence on completion angiogram (Figure 4). The patient was discharged on a direct oral anticoagulant and aspirin. At 3 month follow up in the office a duplex ultrasound demonstrated widely patent axillary and subclavian veins (Figure 5). The patient declined a first rib resection and has stopped lifting weights. At 6 month follow up the patient remains asymptomatic on oral anticoagulation.

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Figure 1.

Venogram demonstrated total occlusion of the left axillary and subclavian veins with collaterals around the occlusion.

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Figure 2.

Patency of vein after suction thrombectomy.

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Figure 3.

Both chronic and acute components removed from occluded veins.

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Figure 4.

Completion angiogram demonstrates absence of collateral veins.

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Figure 5.

Duplex at 3 month follow up demonstrated widely patent axillary and subclavian veins.

A 16-year-old female competitive basketball player presented with a 4-day history of right arm swelling, tingling, heaviness and discoloration. Initial evaluation in the emergency department with ultrasound was negative for DVT. However, repeat exam in the office revealed acute axillary and subclavian vein thrombosis. The patient reported testing positive for COVID-19 1 month earlier with mild symptoms of fatigue and no respiratory complications. She had also been on oral contraceptives sporadically for dysmenorrhea for the previous 3 months.

The following day she underwent right upper extremity venogram which confirmed the diagnosis of axillary and subclavian vein thrombosis. Collateral veins around the occluded vein were also noted (Figure 6). The occlusion was crossed with an Advantage Glidewire (Terumo Medical Corporation, Somersey, New Jersey) and a 0.035 Quick-Cross support catheter (Philips, Koninklijke Philips N.V.) She underwent thrombectomy of the involved veins using the CAT 8 Indigo suction embolectomy catheter from Penumbra (Penumbra Inc. Alameda, California.) This was followed by balloon angioplasty of the veins using a 6 mm balloon followed by a 10 mm balloon, particularly at the area of compression of the subclavian vein at the thoracic outlet (Figure 7). A good radiographic result was obtained with mild residual stenosis and the collateral veins previously noted were now absent (Figure 8). A significant amount of thrombus was removed and estimated blood loss was 200 mL. The patient subsequently underwent first rib resection and her symptoms have improved.

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Figure 6.

Venogram confirmed axillary and subclavian vein thrombosis with collateral veins noted.

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Figure 7.

Balloon angioplasty of the subclavian vein at the thoracic outlet.

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Figure 8.

A good radiographic result was obtained post suction embolectomy and balloon angioplasty with the collateral veins previously noted now absent.

Discussion

Increased potential for thrombosis in both the venous and arterial systems is a well-documented manifestation of COVID-19 infection. This, along with the fact that the 2 young and athletic patients described admitted to an increased workout routine, may have precipitated acute thrombosis of a chronically diseased vein. It is possible that with continued increase in COVID-19 infections we could see a higher incidence of such cases going forward.

The traditional treatment for axillary-subclavian venous thrombosis would be CDT for 24-48 hours requiring close monitoring in an intensive care unit with a small but potentially serious risk for life-threatening bleeding. Mahmoud et. al. have reported equivalent results of upper extremity deep venous thrombosis treatment at 1 year follow-up when comparing CDT versus PMT, however the cost of care was lower with PMT. ⁴

The cost and risks associated with CDT and PMT forms of treatment are eliminated in the new paradigm described above. Even if the attempt is partially successful, the period of time required for thrombolysis and close monitoring could be significantly reduced. Catheter directed therapy with and without pharmaco-mechanical assistance has found increasing relevance in management of acute and sub-acute clot burden. Complications of hemolysis, acute kidney injury and excessive bleeding associated with use of the AngioJet Rheolytic Thrombectomy System (Possis Medical, Minneapolis, MD) has been largely eliminated with the advent of aspiration thrombectomy. Suction thrombectomy using the Indigo system from Penumbra has shown excellent success when dealing with fresh thrombus in the arterial and venous systems, in both the peripheral and coronary vasculature. ⁵ The system consists of a disposable catheter, separator device and a vacuum pump which provides -29 mmHg suction. The catheters come in 4 different sizes of 3.4 F, 5.0 F, 6.0 F and 8.0 F. The CAT 8 suction catheter is large enough to remove substantial amounts of thrombus and the ability of the angulated atraumatic catheter tip to sweep against the wall of the vein enables a more complete thrombectomy. The separator wire allows for clearing of thrombus from the tip of the catheter. The operator does have to use caution to avoid excessive blood loss which can occur when the catheter tip does not engage thrombus. The new Indigo 12 system comes with intelligent aspiration technology which removes clot and switches off in the presence of blood. The new technology does however come with added cost.

Investigators have previously described the use of percutaneous aspiration and thrombectomy devices for the treatment of axillary-subclavian venous thrombosis with adjunctive thrombolysis.^6-10 However, to the best of our knowledge, successful use of the CAT 8 Indigo catheter in this location without concomitant use of thrombolytic agents has not been previously reported. The ability to clear the clot burden without adjunctive use of a lytic agent increases the potential of this treatment paradigm, particularly of benefit in those patients with high risk for bleeding. Additionally percutaneous aspiration and thrombectomy without adjunctive additional ongoing lytic therapy reduces the need for advanced nursing care and ICU monitoring post-operatively and the associated hospital resources. It is conceivable that this intervention could be done in an office-based lab or hospital outpatient facility further reducing the cost of care.

A randomized trial of catheter directed thrombolysis versus thrombectomy with or without adjunctive thrombolysis could provide the answer, however, such a trial is unlikely to be conducted. Technology is rapidly advancing and adoption of new interventions usually does not require large randomized trials to prove their effectiveness.

Conclusion

The pandemic has strained our health care resources to the point that the treatment of non-life-threatening conditions have to be triaged to conserve scarce resources. Axillary-subclavian venous occlusion falls into this category of conditions in that, while usually not life-threatening, timely treatment leads to decreased morbidity and better outcomes. Use of percutaneous aspiration and thrombectomy devices without adjunctive thrombolysis may be of benefit in reducing utilization of healthcare resources while still achieving good outcomes during the COVID pandemic and beyond.