Symptomatic venous thrombosis of the upper extremity complicating permanent transvenous pacing: Reversal with streptokinase infusion

Abstract

Symptomatic deep vein thrombosis of the upper extremity is an infrequently recognized complication of temporary or permanent transvenous cardiac pacing. When present, customary treatment includes elevation, rest, and systemic anticoagulation. We report such an occurrence, refractory to conventional management in whom dramatic improvement was observed subsequent to the institution of thrombolytic therapy with streptokinase. A 62-year-old white male factory worker was admitted to hospital with an acute 48-hour history of right arm edema, venous suffusion, and pain. Three months earlier he had undergone elective implantation of a permanent, transvenous silicone-rubber tined bipolar endocardial pacing catheter (Medtronic No. 6962) using the standard cephalic vein approach. There was no history of recent trauma, significant congestive heart failure, or prior documented thromboembolic phenomenon. On admission the patient was afebrile. The right arm was edematous and cyanotic with prominent superficial venous distention over the anterior deltoid area. The circumference of the arm at mid-bicep level was 5 cm greater than the opposite side. The right axilla was tender but without adenopathy. There was no evidence of cellulitis. The pacemaker incision site was unremarkable and pacemaker function was appropriate. An absolute platelet count and leukocyte count on admission were normal as was a prothrombin time of 11 seconds and a partial thromboplastin time of 27 seconds. A venogram of the involved extremity done on admission (Fig. 1, A) demonstrated complete obstruction of the axillary vein at its mid-point (arrows), with clot extending into the right brachiocephalic system and superior vena cava. Heparin therapy was instituted with a loading dose of 5,000 units followed by a continuous infusion of 1,000 unit&r with observed prolongation of the partial thromboplastin time to 55 seconds. In response to a lack of clinical improvement after 24 hours of heparin therapy, thrombolytic therapy with streptokinase was begun. The anticoagulant effect of heparin was reversed with protamine sulfate. A modified Ivy bleeding time, thrombin time, prothrombin time, partial thromboplastin, and fibrin split product level