Based upon the acute presentation in this patient, the diagnosis of upper extremity deep-vein thrombosis (UEDVT) was believed to be the most likely etiology. The presence of thrombus in the central venous system was confirmed by ultrasound.
Although UEDVT is unusual in a young person, it was important to confirm this first as delay in treatment can lead to increased morbidity and loss of function and future productivity. To pinpoint the etiology, further imaging and consultation with vascular surgery was required.
Duplex ultrasonography of the patient’s left upper extremity revealed an occlusive thrombus involving the subclavian, axillary, and brachial vein to the level of the mid-arm (Figure 2). Further imaging with computed tomography (CT) angiography revealed compression of the neurovascular structures by the first rib.
The patient was admitted for management of her left UEDVT. Therapy with enoxaparin was initiated urgently while awaiting evaluation by vascular surgery. On hospital day one, left upper extremity thrombolysis and balloon angioplasty were performed. The procedures were uncomplicated and complete recannulation was achieved. A hypercoagulable workup was unremarkable. Genetic testing also was performed. The enoxaparin dose was titrated over the next 3 days and the patient was discharged on enoxaparin twice daily. Instructions were given to suspend all repetitive upper extremity activities.