Subclavian Vein Thrombosis Workup

  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Dec 5, 2011
 

Laboratory Studies

  • Patients with suspected thrombophilia should have a full workup for hereditary causes. This should include the following:
    • Lupus anticoagulant
    • Factor V Leiden mutation
    • Protein C
    • Protein S
    • Antithrombin III deficiency
  • If possible, blood levels for these tests should be drawn prior to beginning anticoagulation because the coagulant factors listed above are reduced by heparin.
  • When testing before anticoagulation is not possible, it could be performed 2 weeks after discontinuing anticoagulants or factor X, which is equally affected by warfarin and can be drawn at the same time to serve as a benchmark for protein C and S.
  • Determine patient's complete blood count, prothrombin time, activated partial thromboplastin time, and fibrinogen levels prior to beginning anticoagulants and thrombolytics. Monitor every 6 hours to prevent adverse effects of excessive anticoagulation.
  • Other tests to be performed should be relevant to the cause of the thrombosis.
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Imaging Studies

  • The goal of the evaluation is to objectively verify the presence of thrombus in the subclavian vein. The following imaging studies are useful for evaluation.
  • Chest radiograph: Chest radiograph is generally the initial radiological modality of choice. It may be helpful in the detection of lesions that may be compressing the subclavian vein, such as a cervical rib or an apical lung mass. However, in most cases, the chest radiograph is a very insensitive test and is not useful in determining the cause of subclavian vein thrombosis. In addition, in many cases, the cervical rib is missed on the initial radiograph.
  • Ultrasonography
    • This diagnostic modality (real-time B-mode, duplex Doppler, or color Doppler) has been used increasingly more in the diagnosis of subclavian vein thrombosis.
    • Compared to venography, duplex ultrasonography is very specific but its sensitivity is relatively low.
    • Subclavian vein thrombi not visualized by duplex ultrasonography usually are either nonocclusive mural thrombi or thrombi located in the proximal part of the vein possibly shadowed by the clavicle and sternum. This modality is the test of choice for both screening and follow-up.
    • If this test is negative in the face of strong clinical suspicion, alternative modalities should be used.
  • Venography of the subclavian vein
    • Traditionally, this has been used for diagnosis, but it requires cannulation of a peripheral vein of the arm.
    • Edema of the affected arm sometimes makes this difficult.
    • Digital subtraction may allow the use of a smaller amount of contrast infused into a smaller vein. Venography carries the risk of contrast-induced adverse effects.
    • The technique is only used when thrombosis is highly suspected despite a negative ultrasonographic study.
  • CT scan
    • CT can detect subclavian stenosis, but it has not been sufficiently studied to determine its specificity and sensitivity.
    • CT is sometimes used when venogram and MRI are not readily available. CT requires use of contrast.
    • CT can readily image both the intrathoracic and extrathoracic structures with excellent resolution.
    • Three-dimensional CT angiography rivals MRI and venogram in both resolution and sensitivity.
    • CT can also detect thrombus and the presence of any extrinsic disease that may be causing the subclavian vein thrombosis.
  • MRI: Magnetic resonance imaging (MRI) is very specific for detecting subclavian vein thrombi, but its sensitivity of 80% for thrombi that completely occlude the lumen and 0% for partially occlusive thrombi are too low to be considered reliable.
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Contributor Information and Disclosures
Author

Shabir Bhimji, MD, PhD  Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals

Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven Ugbarugba, MD  Fellow, Assistant Clinical Instructor, Department of Medicine, Section of Gastroenterology, State University of New York at Brooklyn

Steven Ugbarugba, MD is a member of the following medical societies: American College of Physicians

Disclosure: none None None

Chike Magnus Nzerue, MD  Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

William H Pearce, MD  Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University, The Feinberg School of Medicine

William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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