Deep Vein Thrombosis of the Upper Limb: About 6 Cases Collected in Dakar

Deep vein thrombosis of the upper limb is a rare location of venous thromboembolic disease. Data on this form of thrombosis are limited. We report six cases collected in Dakar. The sex ratio was 0.5 and the average age was 27.6 years with extremes of 17 and 39. Painful limb edema was the most constant sign and involved the non-dominant limb in almost all patients. Thrombosis occurred in a field of peripartum cardiomyopathy in two patients and SS sickle cell disease in one patient taking oral contraception. There was neither cancer nor venous catheter in medical history. The diagnosis was made by venous Doppler ultrasound in all patients. Subclavian involvement was the most common. The thrombophilia assessment, done for two patients, was normal. It was about exertion thrombosis on three (3) patients. All the patients had received antivitamin K treatment relaying a low molecular weight heparin. Venous limb compression was associated with anticoagulation for all patients. The treatment duration was six (6) months. There were no reports of pulmonary embolism or death. One patient presented a post-thrombotic syndrome.


Introduction
Deep vein thrombosis (DVT) of the upper limb is a special form of venous

Methodology
This was a descriptive cross-sectional study from April 1, 2015  Data were collected after an informed consent of all patients.

Results
During the period from April 1, 2015 to October 31, 2018, we collected 6 patients.

Observation 1
Mrs. N. K, 26, a housewife, was hospitalized for peripartum cardiomyopathy decompensated by left pneumopathy. This picture was associated with painful edema of the left upper limb, the non-dominant member.
The limb symptomatology dates back to a week before admission, marked by pain and a progressive increase in the volume of the upper limb, from the root of the shoulder to the elbow, extending to the breast. There was no notion of a World Journal of Cardiovascular Diseases venous catheter, nor any specific history.
The examination found an edema of the limb, an increased local heat and a filling of the supra-clavicular hollow. The left breast was painfully edematous with an erythema. Elsewhere, there was a global heart failure syndrome.
The venous Doppler ultrasound showed a basilic and cephalic thrombosis extended to the axillary, subclavian and jugular veins ( Figure 1). Doppler echocardiography found a hypokinetic dilated cardiomyopathy with an ejection fraction of the left ventricle at 20%. The mammogram compared to the breast ultrasound was in favor of mastitis.
A treatment with low molecular weight heparin, overlapped with VKA (acenocoumarol) and associated with venous compression, had been initiated during hospitalization ( Table 1). The evolution was favorable with an almost complete regression of the edema and a sedation of the pain. Acenocoumarol was maintained for six months. The patient seen at the check-up, a year later, had no recurrence or developed post-thrombotic syndrome.
Observation 2 Miss C. E, 21, a right-handed computer science student, was admitted for painful edema of the left upper limb.
Symptoms dated back to five days with waking pain, of moderate intensity, located in the arm. There was no concept of trauma or venous catheter. This persistent pain spread to the entire limb, despite the local application of a non-steroidal anti-inflammatory drug, was accompanied by a progressive increase in the limb with relative functional impotence.
The patient had a SS sickle cell and was on progestin-only oral contraception (medroxyprogesterone acetate). The examination showed painful edema of the limb, with no entry point, or axillary lymphadenopathy. Elsewhere, the examination noted a conjunctival sub-jaundice and a pallor.
The biological assessment found a microcytic anemia at 8.5 g/dl and a negative retroviral serology. A Doppler ultrasound showed a venous thrombosis extending from the subclavian vein to the brachial vein.    Table 2).
The course after a few days of anticoagulation was marked by a partial regression of the edema. After one month, we noticed an edema of the hand and forearm ( Figure 2).     Table 2).
The patient was put, during hospitalization, on LMWH with an overlapping curative dose, then relayed by VKA (acenocoumarol). He also had venous compression.
The outcome was favorable for stopping treatment at 6 months, with complete regression of the edema. At the one-year follow-up, the patient had not presented a recurrence or post-thrombotic syndrome.

Discussion
Upper limb DVT affected young adults in our work, with an average age of 27.6 years, as found in the literature with a median age between 30 -35 years [5].
However, our patients were younger than those in the literature [3] [4] [6]. DVT of the upper limb can occur at any age; the age of onset depends on the etiology.
The predominance of women in our study was observed by Mustafa and Co.
and Codjo and Co. [4] [7]. The small size of our population does not allow us to conclude, on any predisposition of the female sex, a risk of DVT of the thoracic limb.
The clinical signs of inflammation were the most common signs seen in our study. Pain was present in five (05) of our patients, Marie and Co. found 81.6% [6] and Codjo and Co, 100% [4]. Edema was noticed in all our patients. Other manifestations were noticed, such as heaviness (present in one of our patients) or limb tension which were relieved by elevation, axillary or cervical pain, paresthesia of the limb, secondary to irritation of the brachial plexus [8].
The diagnosis of venous thrombosis of the upper limb is primarily clinical. As with the lower limb, the clinical signs of thrombosis of the upper limb are related to the obstruction and the resulting inflammation. The venous Doppler ultrasound allowed the diagnosis to be made in all of our patients. It specified the location and extent of the thrombosis. It is the first-line diagnostic method in the vast majority of cases [9]. In the absence of thrombosis, it authenticates a stasis, localizes an extrinsic compression and directs towards other differential diagnoses (compressive hematoma or muscular compartment) [10]. Phlebography should be reserved in case the ultrasound is negative or difficult with a high degree of suspicion [11].
In our work, no risk factor was found. DVT of the upper limb was primary in three (03) patients. One of the patients was a dressmaker (knitting, beading) and the other two were pupil and student. Primary upper limb DVT is a very heterogeneous category and includes both exercise-induced DVT and idiopathic DVT. Primary DVT requires a rigorous physical examination, in particular the performance of dynamic maneuvers (syndrome of the parade) and the exhaustive search for coagulation abnormalities. In the absence of a standardized defi-World Journal of Cardiovascular Diseases nition of effort considered as intense, the allocation of patients to one or the other of these two groups is sometimes arbitrary [8]. Intense sporting activity is not always necessary. Sanson and Co. [12] reported a case of venous thrombosis associated with the daily wearing of a backpack and a profession of the patient related to that of a fastfood cook [13].
In three (03) patients, DVT occurred in a field at increased risk of thrombosis: homozygous sickle cell anemia and peripartum cardiomyopathy.
DVT of the secondary upper limb is the most frequent, i.e. two thirds of the cases, linked to intravenous devices and cancers [3]. No case of thrombosis linked to a central venous catheter had been found. Kane and Co reported two (02) cases of DVT on pace maker [3]. For patients with intravenous devices, a large number of DVTs of the upper limb go unnoticed in the acute phase [14]. If a routine ultrasound was performed, almost a quarter of patients with pacemakers would be diagnosed with DVT, while the symptomatic upper limb DVT rate is only 2% [15].
Heparin therapy relayed by VKA (acenocoumarol) was the most often used treatment protocol. One patient had received VKA treatment directly. The duration of treatment was of 6 months in all patients. It is specified that the protocol for determining this duration must be "similar" to that for deep vein thrombosis of the lower limb [10]. The duration of anticoagulation is not the subject of a universal consensus; conventionally, a treatment period of at least three months should be recommended. Thereafter, treatment may be discontinued if a transient promoting factor is found. Conversely, an extended period of at least one year is the rule in the presence of a permanent promoting factor, or if DVT is considered to be idiopathic [16]. All of our patients received venous compression. The effect of this compression on the occurrence of post-thrombotic syndrome is not proven [17].
In our work, there was no case of pulmonary embolism. DVT of the upper limb has long been considered a mild condition. The risk of PE is certainly lower than in the case of DVT of the lower limb but remains clinically significant. It is 5% of symptomatic embolism [17].
On the other hand, the occurrence of post thrombotic syndrome is very high (in 20% of cases [12]). One of our female patients had post thrombotic syndrome with cessation of professional activity. These complications are favored by the proximal nature of DVT [12].
A recurrence at 5 years is reported in 8% of the cases [18].

Conclusion
Data on upper limb deep vein thrombosis are limited. The profile of our patients is different from the rare cases published. The etiology approach is a real challenge for appropriate care. Multicentric work is necessary to better understand the profile of patients with venous thrombosis of the upper limb in Sub-Saharan Africa.