Understanding Upper Limb Swelling: Signs of Thoracic Outlet Vein Occlusion

Author: Zhang Xiaoyu, Attending Physician of the Vascular Surgery Department at Shanghai First People's Hospital. Reviewer: Ding Qingwei, Associate Chief Physician of the Vascular Surgery Department at Shanghai First People's Hospital.

Understanding Upper Limb Swelling: Signs of Thoracic Outlet Vein Occlusion Introduction: Upper arm venous occlusion causes limb swelling, often misdiagnosed; awareness can improve timely treatment and quality of life. Keywords: ['Cardiovascular', 'Health education'] Main text: Life examples: Recently, a 40-year-old patient who had been suffering from swelling in the left upper limb for many years visited the vascular department of the First Municipal Hospital. Over ten years ago, the patient underwent surgery for malignant lung tumors at a local hospital, followed by long-term oral targeted therapy. Five years ago, due to occlusion of the brachiocephalic vein, the patient underwent endovascular treatment at a local hospital, which was unsuccessful in reopening the blocked vein. As time went on, the swelling in the left upper limb became increasingly severe. This time, the vascular department successfully reopened the occluded vein. After the surgery, the patient was prescribed regular oral anticoagulants and decongestants, along with pressure therapy. Currently, the swelling in the left upper limb has significantly improved compared to before the surgery. The clinical manifestations lack specificity, making it susceptible to missed diagnosis. What is the brachiocephalic vein? The brachiocephalic vein, also known as the innominate vein, is an important venous vessel located in the upper thorax of the human body, with one on each side. They are formed by the confluence of the internal jugular vein and the subclavian vein and ultimately drain into the superior vena cava, responsible for returning blood from the head, neck, and upper limbs to the heart. In simple terms, the brachiocephalic vein acts like the main highway for blood transport in the body; any blockage can directly affect the blood circulation in the upper half of the body. The causes of brachiocephalic vein occlusion can be primarily classified into two categories: external compression and internal thrombosis. External compression is usually the most common cause, with tumors, benign occupying lesions, and fibrotic diseases being the main factors. On the other hand, central venous catheters, hypercoagulable states, and radiation therapy can easily lead to thrombosis within the brachiocephalic vein itself. Patients often seek medical attention due to upper limb swelling, which can have multiple causes, making it generally difficult to initially consider brachiocephalic vein occlusion, thus resulting in a high rate of missed diagnosis for this condition. Symptoms are gradually worsening, affecting the quality of life. The most common clinical manifestation of superior vena cava obstruction is swelling of the affected limb, often accompanied by a heavy, aching sensation. As the narrowing of the superior vena cava worsens and even leads to obstruction affecting the blood supply to the superior vena cava, patients may not only experience typical limb swelling symptoms but may also develop superficial venous dilation of the chest wall, difficulty breathing, hoarseness, and even cyanosis, significantly impacting the patient's daily life. Minimally invasive interventional surgery is the primary treatment method. For patients with such narrow or obstructed conditions, the primary treatment method is minimally invasive intervention. The treatment goals are to relieve the obstruction, alleviate symptoms, and prevent recurrence. During the procedure, local anesthesia is used, and under ultrasonic guidance, successful puncture of the left axillary vein is achieved. After passing a guide wire through the obstructed segment of the brachiocephalic vein, balloon dilation of the brachiocephalic vein is performed, followed by the implantation of a bare stent. Post-operative angiography shows the visualization of blood flow in the unnamed vein, confirming the patency of the lumen. For some cases where interventional treatment fails, surgical thrombectomy or thoracic outlet decompression can be considered to further relieve vascular compression. Emphasize the management of the underlying causes and postoperative medication. Etiological treatment is crucial in the management of upper limb venous occlusion. Clinicians must actively identify and address the underlying causes, such as compression from external tumors (e.g., lung tumors, lymphoma), which may require tumor removal or combined chemotherapy and radiotherapy. If there is catheter-related thrombosis or the patient has an inherent tendency for thrombosis, anticoagulation therapy should be implemented, along with an assessment of the timing for catheter removal. In cases where minimally invasive surgery involves the implantation of a metal stent, long-term anticoagulation is typically needed postoperatively to prevent thrombosis within the stent. Summary: Occlusion of the brachial veins, especially in the case of acute onset, often leads to sudden limb swelling in patients. The cause of this swelling can easily be confused with heart or kidney failure, lymphatic circulation disorders, or inflammatory infections. When a patient experiences unexplained swelling in a limb, they should seek medical attention immediately. The treatment plan should be developed collaboratively by a multidisciplinary team, including vascular surgery and radiology specialists.