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Venous TOS Symptoms

Venous TOS is when the axillary-subclavian vein is compressed within the costoclavicular space between the first rib and the collarbone.  There are two types of VTOS.  The first type is the thrombotic form which involves a blood clot (called an effort thrombosis) and is known as Paget-Schroetter Syndrome.  The second type is a non-thrombotic form which involves symptomatic intermittent positional compression of the vein but no blood clot and is known as McCleery Syndrome.

THROMBOTIC VTOS

(PAGET-SCHROETTER SYNDROME)

A blood clot is a gel-like collection of blood that forms in your veins or arteries when blood changes from liquid to partially solid.  The axillary-subclavian vein is considered a deep vein, so when a blood clot forms within it, it is considered to be a deep vein thrombosis or DVT. Because the veins return blood back to the lungs and the heart, a DVT can break loose and travel to the lungs resulting in a pulmonary embolism which can be life threatening.  Although the risk of this occurring with an upper extremity DVT is not as high as with a DVT of the lower extremity, it can still be around 10-20%. In the case of VTOS, chronic damage occurs to the vein from repeatedly being compressed by the rib and surrounding structures which leads to scar tissue and thickening of the wall of the vein causing the inside of the vein to become narrowed.  The clot forms as a result of stagnant and turbulent blood flow through the narrowed part of the vein.  This process can take quite awhile with symptoms not immediately appearing because the body forms new veins called collateral veins to help keep the blood flowing by taking a different route.  This is similar to when a serious traffic accident closes part of a highway and the cars end up getting rerouted to side streets to take a different path to get to their destination.  A blood clot in a vein obstructs the vein preventing blood from flowing through it.  When the axillary-subclavian vein becomes obstructed, blood in the arm cannot flow back to the heart and thus it becomes trapped in the arm which is what causes the arm to be swollen and tight.  Once a blood clot forms, symptoms usually follow soon thereafter.

DVT

Symptom Features:

  • Patient population split evenly between male and female

  • Most frequently presents in patients ages 15-35, but can & does occur outside of this range

  • Patients are typically young, healthy, and active

  • Usually presents on 1 side of the body at a time

  • Symptoms typically present with sudden onset and are very dramatic, but not always

  • Can often present immediately following an activity requiring heavy arm usage especially repetitive and overhead

Most Common Symptom Presentation:

  • Sudden onset of swelling of the entire arm and hand typically starting at the level of the shoulder.  Swelling is usually quite significant with the diameter of the arm being twice the diameter of the unaffected arm.

  • Blue, purple or red discoloration of the arm and hand

  • The arm and hand will often feel warmer or hot compared to the unaffected arm

  • Fatigue, tightness, heaviness, aching or pain in the arm and hand particularly when trying to use it

  • Very visible, large collateral veins can often be seen across the chest and the front of the shoulder

  • Shortness of breath and chest pain can occur if the clot has traveled to the lungs resulting in a pulmonary embolism

  • Rarely, patients with VTOS will also have NTOS.  Click here to learn more about the symptoms of NTOS.

Less Common Symptom Presentation:

  • Minimal or no swelling

  • Intermittent swelling that continues for weeks or months which is activity dependent

  • No visible collateral veins on the chest and front of the shoulder

  • No arm and hand discoloration

  • Heaviness, fatigue, aching or pain only intermittently which is typically activity dependent

  • Usually diagnosed as a result of a flare up of intermittent symptoms or when testing to rule out other conditions or other types of TOS

NON-THROMBOTIC VTOS

(McCLEERY SYNDROME)

With non-thrombotic VTOS, symptoms of vein compression are intermittent and not due to formation of a blood clot.  This type of VTOS is less common than the thrombotic form.  Most surgeons will offer to operate with this form of VTOS, but others recommend only conservative treatment until such time that a clot occurs.  Vein compression with the arm elevated without symptoms of venous congestion is NOT considered to be VTOS.

swollen and discolored arm venous TOS

swollen and discolored right arm

upper arm collateral veins

swollen and discolored right arm with collateral veins

Symptom Features:

  • Patient population split evenly between male and female

  • Most frequently presents in patients ages 15-35, but can & does occur outside of this range

  • Patients are typically young, healthy, and active

  • Usually presents on 1 side of the body at a time, but can be on both sides

  • Symptoms are only present during activities of heavy arm usage especially repetitive or overhead and then resolve when the arm is at rest

Symptoms:

  • Arm and hand swelling (typically not as significant as with thrombotic VTOS)

  • Blue, purple or red discoloration of the arm and hand

  • Fatigue, tightness, heaviness, aching or pain in the arm and hand

  • Warmth or hot feeling of the arm and hand

  • Bulging veins in the arm and hand

SKIP TO:

chest collateral veins

collateral veins on chest

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