Acute Superficial Vein Thrombosis of the Upper Extremity: A Case Report

Abstract

Superficial vein thrombosis has traditionally been considered a disease of the lower extremity. Less frequently it can affect the breast, chest wall, penis, or upper extremity. Cases involving upper extremities are usually associated with intravascular access, and the vast majority remain self-limiting. This case report presents a 63-year-old patient who had acute extensive thrombosis of cephalic and basilic venous systems following resection of a desmoid tumor from the flank. This was likely related to intraoperative positioning and resulted in severe symptoms mimicking deep vein thrombosis and carpal tunnel syndrome. Additionally, diagnostic tools available to the hand surgeon that allow prompt diagnosis, management, and prevention are discussed.

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Disclosure: None of the authors has a nancial interest in
any of the products, devices, or drugs mentioned in this article.
From the Department of Plastic Surgery, Cleveland Clinic,
Cleveland, Ohio.
Received for publication August 26, 2020; accepted October 21,
2020.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
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DOI: 10.1097/GOX.0000000000003322
Hand/Peripheral Nerve
Supercial thrombophlebitis is an inammation of
the supercial veins associated with supercial vein
thrombosis (SVT). Traditionally, it has been consid-
ered a disease of the lower extremity.1 Less frequently, it
can affect the breast, chest wall, penis, or upper extrem-
ity.2–6 Cases involving upper extremities are primarily
associated with intravascular access and usually remain
self-limiting. This report presents a patient who developed
acute thrombosis of cephalic and basilic venous systems,
likely related to intraoperative positioning, that mani-
fested with severe symptoms.
CASE REPORT
This case involves a 63-year-old right-hand-dominant
ofce worker who presented for resection of a right
ank desmoid tumor. Her BMI was 21.7 kg/m2. Relevant
past medical history included hypertension treated with
oral lisinopril 10 mg QD, and left greater saphenous
SVT following shoulder surgery for adhesive capsulitis
8 years prior, for which she had received a 2-month-
long course of subcutaneous enoxaparin 40 mg QD. Past
medical work-up was negative for hypercoagulopathy
and malignancy. The patient denied a prior history of
hand trauma or compression neuropathy. Her Caprini
score was 7.
On the day of surgery, a peripheral intravenous line
was placed in the left dorsal hand and intravenous normal
saline infusion started 2 hours before surgery. The patient
was given 5000 IU of unfractionated heparin for deep vein
thrombosis (DVT) prophylaxis and was then taken to the
operating room, placed under general anesthesia, and posi-
tioned in the left side down lateral decubitus position with
an axillary roll. The tumor was radically resected and the
defect was closed primarily in 87 minutes. Immediately after
the procedure, the surgical team noted generalized edema,
discoloration, tenderness, and coolness of the left hand with
paresthesias in the median nerve distribution. One hour
after surgery, swelling and discoloration propagated to the
level of the mid-forearm despite extremity elevation (Fig.1).
At that time, differential diagnosis included DVT. A bed-
side ultrasound performed by the hand surgery team using
Sonosite Edge 7-MHz linear transducer (FUJIFILM Sonosite
Inc., Bothwell, Wash.) and the technique described before
revealed thrombosis of the basilic and cephalic veins extend-
ing from the level of the proximal arm to the distal forearm
(Fig.2).5 There were no arterial or deep vein abnormalities
noted. A formal duplex ultrasound was then requested and
conrmed this diagnosis. The vascular medicine service
was consulted and initiated continuous medium-level com-
pression therapy with elastic glove and sleeve, oral ibupro-
fen 400 mg QID, and subcutaneous enoxaparin 40 mg QD.
Hypercoagulability work-up was negative. On postoperative
day 1, coolness and paresthesias resolved, and the patient was
discharged from the hospital.
At 2 weeks postoperative, repeat left arm duplex
showed no propagation of the thrombus and no DVT. Due
to patient’s preference and persistent swelling and palpa-
ble cords along the involved veins, decision was made to
switch enoxaparin to therapeutic dose oral rivaroxaban
Grzegorz J. Kwiecien, MD
Demetrius M. Coombs, MD
Nicholas Sinclair, MD
Brian R. Gastman, MD
Bahar Bassiri Gharb, MD, PhD
Antonio Rampazzo, MD, PhD
Summary: Supercial vein thrombosis has traditionally been considered a disease
of the lower extremity. Less frequently it can affect the breast, chest wall, penis,
or upper extremity. Cases involving upper extremities are usually associated with
intravascular access, and the vast majority remain self-limiting. This case report
presents a 63-year-old patient who had acute extensive thrombosis of cephalic and
basilic venous systems following resection of a desmoid tumor from the ank. This
was likely related to intraoperative positioning and resulted in severe symptoms
mimicking deep vein thrombosis and carpal tunnel syndrome. Additionally, diag-
nostic tools available to the hand surgeon that allow prompt diagnosis, manage-
ment, and prevention are discussed. (Plast Reconstr Surg Glob Open 2020;8:e3322; doi:
10.1097/GOX.0000000000003322; Published online 21 December 2020.)
Acute Supercial Vein Thrombosis of the Upper
Extremity: A Case Report
CASE REPORT

PRS Global Open • 2020
2
20 mg QD. At 8 weeks post-operatively, the swelling and
discoloration were minimal but the palpable, tender
cords persisted. Ultrasound showed partial resolution of
the thrombus, extending from the distal arm to the distal
forearm. At the present time, 3 months post-operatively,
patient’s symptoms have resolved and she was advised to
discontinue compression and anticoagulation.
DISCUSSION
SVT of the upper extremity is usually a self-limiting
condition.7 Herein, we present a patient with extensive
thrombosis of cephalic and basilic veins, resulting in acute
venous congestion mimicking DVT and acute carpal tun-
nel syndrome.
Diagnosis
Diagnosis of SVT is usually clinical, especially when ten-
der and inamed veins can be identied.2,8 Vascular ultra-
sound is often performed to conrm the diagnosis and to
rule out coexisting DVT or other pathologies—eg, arterial
thrombosis, pseudoaneurysm, and venous incompetence,
among others. SVT may coexist with DVT in 5%−53% of
Fig. 1. Appearance of patient’s hands 1 hour after surgery. Marked venous congestion of the left hand
and distal forearm can be appreciated on the dorsal (A) and volar (B) view.
Fig. 2. Sonographic visualization of the cephalic vein (V) at the midforearm level. A, Appearance of the
thrombosed cephalic vein (V) without compression. B, Appearance of the thrombosed cephalic vein
with compression by the ultrasound probe. Inability to collapse the vein conrms the presence of a
thrombus within the vessel lumen.

Kwiecien et al. • Acute Venous Thrombosis in the Upper Extremity
3
patients.9,10 Furthermore, when it involves veins near the
junction with the axillary vein, it is considered an equivalent
of DVT.9,10 Bedside ultrasound performed by a surgeon has
been shown to be an efcient tool in diagnosis of numer-
ous conditions of the upper extremity.11,12 In this case, it
facilitated prompt diagnosis without the delay associated
with formal ultrasound performed by a technician. This
is crucial, as delay in treatment may cause propagation of
the supercial thrombus, with progression to proper DVT
and pulmonary embolism.9,10,13 Delayed treatment has also
been shown to contribute to permanent skin discoloration
and infections.8 Finally, the patient likely had subclinical
carpal tunnel syndrome, which became symptomatic with
acute wrist swelling.14 Bedside ultrasound can be used to
evaluate diameter of the median nerve. Although it was
not performed in the presented case, an increase in cross-
section area of the nerve may guide treatment.
Treatment
In most cases, SVT is a self-limiting condition and treat-
ment is mainly symptomatic with warm compresses, anti-
inammatory medications, compression, and elevation.
When symptoms are severe, the thrombus is extensive,
or it is in close proximity of the vessels emptying into the
deep venous system, an anticoagulant is usually used to
minimize the risk of progression to DVT and subsequent
pulmonary embolism. Occasionally, when a patient can-
not tolerate anticoagulation, a close follow-up with serial
ultrasound or surgical thrombectomy may be indicated.2
The patient presented was treated with all available non-
surgical modalities. Despite aggressive management, her
symptoms did not resolve until 3 months after surgery,
indicating that SVT can be a debilitating complication.
Prevention
Understanding risk factors for SVT is a key to pre-
vention.7 The patient had several risk factors, including
intravenous line, age over 60 years, prior history of SVT,
and duration of the procedure over 45 minutes. In addi-
tion, the lateral decubitus position with an axillary roll
likely caused external pressure on the proximal arm that
impaired venous outow, established intravascular stasis,
and ultimately predisposed her to thrombosis. Avoiding
intravenous lines and pressure cuffs in the extremity in
downward position, alternative choice of positioning, use
of compression devices or garments, or prophylactic pre-
and postoperative anticoagulation in high-risk patients
may minimize the risk for both DVT and SVT. Finally,
recurrent episodes of SVT, often termed migratory throm-
bophlebitis, should be investigated for possible underly-
ing malignancy—eg, Trousseau’s syndrome.
CONCLUSIONS
Upper extremity SVT can present with severe symp-
toms when cephalic and basilic veins are involved. Bedside
ultrasound performed by a surgeon is an excellent tool
that can provide immediate answers and prevent unnec-
essary delays in treatment. Despite immediate treatment,
symptoms of SVT can persist for months, substantially
affecting patients’ recovery and satisfaction.
Antonio Rampazzo, MD, PhD
Cleveland Clinic, Department of Plastic Surgery, Desk A60
9500 Euclid Avenue
Cleveland, OH 44195
E-mail: rampazza@ccf.org
REFERRENCES
1. Di Nisio M, Wichers IM, Middeldorp S. Treatment for super-
cial thrombophlebitis of the leg. Cochrane Database Syst Rev.
2013;4:CD004982.
2. Cosmi B. Management of supercial vein thrombosis. J Thromb
Haemost. 2015;13:1175–1183.
3. Bird V, Krasnokutsky S, Zhou HS, et al. Traumatic thrombophle-
bitis of the supercial dorsal vein of the penis: An occupational
hazard. Am J Emerg Med. 1997;15:67–69.
4. Loos B, Horch RE. Mondor’s disease after breast reduction sur-
gery. Plast Reconstr Surg. 2006;117:129e–132e.
5. Ploton G, Pistorius MA, Raimbeau A, et al. A STROBE cohort
study of 755 deep and supercial upper-extremity vein thrombo-
sis. Medicine (Baltimore). 2020;99:e18996.
6. Bleker SM, van Es N, Kleinjan A, et al. Current management
strategies and long-term clinical outcomes of upper extremity
venous thrombosis. J Thromb Haemost. 2016;14:973–981.
7. Chin EE, Zimmerman PT, Grant EG. Sonographic evaluation
of upper extremity deep venous thrombosis. J Ultrasound Med.
2005;24:829–38; quiz 839.
8. Nasr H, Scriven JM. Supercial thrombophlebitis (supercial
venous thrombosis). BMJ. 2015;350:h2039.
9. Chengelis DL, Bendick PJ, Glover JL, et al. Progression of super-
cial venous thrombosis to deep vein thrombosis. J Vasc Surg.
1996;24:745–749.
10. Bergqvist D, Jaroszewski H. Deep vein thrombosis in patients
with supercial thrombophlebitis of the leg. Br Med J (Clin Res
Ed). 1986;292:658–659.
11. Jacob DD, Kwiecien GJ, Cakmakoglu C, et al. Color duplex ultra-
sound for localization of vascular compromise in microsurgical
breast reconstruction. Plast Reconstr Surg. 2020;145:666e–667e.
12. Vögelin E. Ultrasonography: The third eye of hand surgeons. J
Hand Surg Eur Vol. 2020;45:219–225.
13. Cascella M, Viscardi D, Bifulco F, et al. Postoperative massive
pulmonary embolism due to supercial vein thrombosis of the
upper limb. J Clin Med Res. 2016;8:338–341.
14. Figus A, Iwuagwu FC, Elliot D. Subacute nerve compres-
sions after trauma and surgery of the hand. Plast Reconstr Surg.
2007;120:705–712.