Upper extremity deep vein thrombosis

　　Axillary-subclavian vein thrombosis is usually divided into two major categories: primary and secondary. The specific content is as follows:

　　1, Primary pathogenic causes Primary pathogenic causes are outside the blood vessels, generally due to changes in the position of the upper limb or strong activity, causing vascular compression, which may be accompanied or without anatomical abnormalities, leading to thoracic outlet syndrome, such as the subclavian vein being compressed by the costoclavicular ligament, subclavius muscle, anterior scalene muscle, and prominent scalene tubercle when passing through the costoclavicular triangle. When the upper limb is subjected to strong activity (swimming, climbing, weightlifting, baseball, tennis, etc.), or due to certain occupational movements that are unnatural for the upper limb, the subclavian vein may suffer repeated injury and intimal thickening, eventually leading to thrombosis. This is what is traditionally known as Paget-Schroetter syndrome, also known as 'traumatic' venous thrombosis.

　　2, Secondary pathogenic causes There are many secondary causes, such as catheter or wire placement in the blood vessels, injection of irritant drugs, etc. After venous catheterization, about 1/3 of the patients may develop thrombosis, of which 1% to 5% have clinical symptoms. In addition, there are heart failure, pregnancy, oral contraceptives, coagulation and fibrinolysis dysfunction, arteriovenous fistula of hemodialysis, and other causes. Some pathogenic causes are outside the blood vessels, such as cancer, radiotherapy, first rib or clavicle fracture, and so on.

　　Pulmonary embolism and post-thrombotic syndrome are common complications of deep vein thrombosis of the upper limb.

　　1, Pulmonary embolism is a clinical and pathophysiological syndrome caused by the obstruction of the pulmonary artery or its branches by endogenous or exogenous emboli, leading to pulmonary circulation impairment.

　　2, Post-thrombotic syndrome refers to symptoms such as nausea, vomiting, local pain, fever, reflexive ileus or paralytic ileus, decreased appetite, and other symptoms caused by tissue ischemia and necrosis after tumor and organ arterial embolism.

　　Deep vein thrombosis of the upper limb can occur in both males and females, and it can occur at any age, with secondary cases often having identifiable causes. Paget-Schroetter syndrome (primary) is more common in middle-aged and young male adults, with 2/3 of the lesions occurring in the right upper limb, which may be related to the greater exertion of the right upper limb. Four-fifths of the patients have a history of trauma within 24 hours before onset, such as vigorous upper limb activity or prolonged upper limb positioning in an unnatural posture. About 1/10 of the patients may have no apparent cause, just waking up in the morning after a night's sleep.

　　Swelling, pain, skin cyanosis, and superficial varicose veins are the four main symptoms. Swelling of the upper limb is the earliest symptom, extending from the fingers to the upper arm and affecting the entire upper limb, with the proximal part being more severe. Pain may occur simultaneously with swelling or may only manifest as acid and胀, exacerbated during the movement of the upper limb, and sometimes palpable thrombophlebitis can be felt, with about 2/3 of the patients suffering from venous congestion. The affected limb may change to purple or blue, and superficial varicose veins usually form within 1 to 2 days, being most prominent in the shoulder and upper arm. Most patients' acute symptoms such as swelling and pain may resolve spontaneously within a few days or weeks, but it is difficult to achieve complete recovery, with more than 2/3 of the patients having residual lesions, manifested as varying degrees of swelling and soreness, or swelling and pain after activity.

　　There is no special method to prevent upper extremity deep vein thrombosis, the general principle is to form a proper lifestyle and promote physical and mental health.
　　1. Maintain good dietary habits, such as quitting smoking and drinking, not eating too much salted vegetables and sour, spicy, and刺激性 foods, and avoiding moldy foods. Pay attention to food hygiene and nutrition.

　　2. Maintain good living habits. In cold seasons, keep the indoor temperature and humidity appropriate, pay attention to air circulation. The room temperature should be around 20℃, and do not cover too many quilts during sleep at night to avoid excessive temperature or dryness, causing discomfort in the throat. Do not sleep with the wind, rest for a while after strenuous labor, and do not take a cold shower immediately, etc.

　　The diagnosis of upper extremity deep vein thrombosis is mainly made through the following examinations, the specific content is as follows:

　　1. Duplex Doppler ultrasound examination

　　It can observe the transverse and longitudinal sections of the axillary vein, subclavian vein, innominate vein, and internal jugular vein. Direct signs can show the location and extent of venous stenosis or occlusion; indirect signs include amplitude attenuation, reduced flow rate, pulse migration deficiency, and significant stenosis or occlusion at the end of respiration. For patients without direct signs of lesions, it should be checked on the healthy side and compared with the affected side.

　　2. Deep vein angiography

　　It is of great value in formulating treatment plans, venography can show venous stenosis or occlusion in the affected limb.

　　Patients with upper extremity deep vein thrombosis should consume a diet rich in vitamins (celery, chives, coarse grains, beans), high in protein (meat, fish, dairy products), high in calories (milk, cakes, eggs, sweets), and low in fat (avoid fatty meat, egg yolks, brain). The diet should mainly consist of fluid or semi-fluid light foods, and spicy, sweet, and fatty foods should be avoided to prevent increased blood viscosity and worsen the condition. Here are three food therapy recipes for your reference.
　　1. Take 6 grams of black fungus, soak it in water, and add it to dishes or steam it. It can lower blood lipids, prevent thrombosis, and inhibit platelet aggregation.
　　2. Take 5 roots of celery and 10 red dates, decoct in water, eat the dates and drink the soup. It can reduce blood cholesterol levels.
　　3. Consume fresh hawthorn or brew hawthorn in hot water, add an appropriate amount of honey, cool it down and drink it as tea. Hawthorn can dilate blood vessels and has the effects of lowering blood pressure and promoting cholesterol excretion.

　　The treatment for upper extremity deep vein thrombosis includes three aspects: acute thrombosis treatment, extravascular compression treatment, and the treatment of post-thrombotic venous lumen stenosis.

　　For acute thrombosis without obvious clinical manifestations, treatment may not be required as the thrombus often dissipates in a short period of time. For those with obvious symptoms and signs, anticoagulation and fibrinolytic therapy are required; if symptoms do not improve after thrombolysis, and there is still pain, swelling, and cyanosis in the affected limb, surgical treatment should be considered. If the cause is compression by the first rib, excision of the compressed rib segment and relaxation of the compressed venous segment should be performed. If there is short-segment stenosis or occlusion of the vein, venous patch plasty should be added. If the lesion segment of the subclavian vein is very close to the heart end, and bleeding cannot be effectively controlled during surgery, venous balloon dilatation plasty can be performed in the later stage. For those who are completely occluded or severely stenosed and cannot undergo various venoplasty procedures, jugular vein displacement surgery can be performed. For thrombosis caused by external compression of the veins, 40% of patients have significant functional impairment after conservative treatment. Therefore, active treatment measures should be taken.

　　In addition, when there is severe stenosis or occlusion of the subclavian vein and it is not possible to use patch plasty or balloon dilatation plasty, various venous shunt operations can be performed. It is generally believed that the operation of internal jugular vein displacement is the simplest and most effective. The specific method is to expose and dissect the subclavian vein through the subclavian approach, make a transverse incision above the clavicle and below the mandible, free the internal jugular vein, cut it at the point where it enters the skull, tie the distal end, invert the proximal end, and perform an end-to-side anastomosis with the subclavian vein through the posterior clavicle channel.

　　In terms of treatment, the following issues should be paid attention to:

　　1. Selection of Surgical Timing: It is generally believed that anticoagulation and thrombolytic therapy should be performed as soon as possible after thrombosis; for those with residual thrombus or luminal stenosis after thrombolysis, surgical treatment should be considered. Generally, the generation of vascular wall cytokines is at least higher than the normal value within 1 month after thrombosis destroys the venous endothelium, and the fibrinolytic activity of the endothelium is at least lower than the normal value within 3 months. Therefore, to avoid recurrent thrombosis, surgery should be performed within 1 to 3 months.

　　2. Temporary Arteriovenous Fistula: Generally, it is recommended to perform a temporary arteriovenous fistula at the distal side of the venous repair and reconstruction segment to improve the long-term patency rate. The graft material can be autologous great saphenous vein or 6mm PTFE, and the fistula should be closed after 3 months.