A 45-year-old woman presented to her family doctor following a three-day history of acute-onset, progressive swelling and sensation of heaviness in her left upper extremity. In addition, she described pleuritic chest pain and dyspnea on exertion. Five days before presentation, she had been lifting heavy furniture and boxes and had performed her regular exercise routine that involved lifting 10-and 15-pound weights overhead. She had no history of thrombosis and no family history of clotting disorders. Her medical history included Hashimoto thyroiditis and remote iron deficiency anemia secondary to menorrhagia. Cancer screening had yielded normal results on a Papanicolaou test and a colonoscopy performed three years earlier. She had no recent immobilization, surgery or long-distance travel and was not taking supplemental estrogen. The patient was referred to the emergency department for evaluation of suspected deep vein thrombosis (DVT) in her left upper extremity and pulmonary embolus.In the emergency department, she had a regular heart rate of 96 beats/min and an oxygen saturation of 95% on room air. Her temperature and blood pressure were within normal limits. There was obvious swelling of the entire left upper extremity, dilated subcutaneous collateral veins over the anterior shoulder, and mild cyanosis in the hand and fingers. Neurologic and arterial examinations of the upper extremities yielded normal findings. Venous duplex ultrasonography showed an occlusive thrombus in the left subclavian and axillary veins. Computed tomography pulmonary angiography showed pulmonary emboli in the bilateral subsegmental arteries. The patient was admitted, and treatment with low-molecular-weight hep arin was started.The following morning, the patient underwent peripheral venography (Figure 1) with catheter-directed thrombolysis using a tissue plasminogen activator. She subsequently received ongoing anticoagulation with intravenous unfractionated heparin. A follow-up venogram 24 hours after the thrombolysis showed resolution of the clot; however, severe stenosis of the left subclavian vein was noted. Angioplasty of the stenotic area was only partially successful, leaving residual stenosis of the subclavian vein in the neutral position, with dynamic occlusion on abduction of the left upper extremity (Figure 2). Two days later, the patient was discharged home and prescribed low-molecularweight heparin.Two months after discharge, the patient underwent an uncomplicated transaxillary resection of the left first rib to relieve compression of the subclavian vein. Venography performed one month later showed resolution of the subclavian vein stenosis and of the dynamic occlusion (Figure 3). In discussion with her treating physician, the patient elected to complete a further three months of anticoagulation with therapeutic doses of low-molecular-weight heparin instead of transitioning to oral anticoagulation following her surgery. She experienced good functional recovery of her left upper extremity, with no recurrence of DVT.

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