Abstract Deep vein thrombosis (DVT) of the upper extremity is rare, comprising only about 5% of all reported DVTs. Most common causes include indwelling central venous catheters, cardiac pacemaker/defibrillator, malignancy, and thrombophilic mutations. Thrombus of the superior vena cava (SVC) is even more rare. Due to its indolent nature, an upper extremity DVT has a threefold increased risk of developing limb ischemia, which can then progress to necrosis and eventual limb loss. Here, we discuss a case of extensive limb ischemia that was complicated by septic shock, eventually leading to the patient’s demise. A 35-year-old female presented to the hospital complaining of right arm pain, exertional dyspnea, and generalized malaise for one week. On arrival, vital signs were significant for BP 85/50, HR 125, and oxygen saturation 87% on room air. Physical exam was remarkable for a dusky appearing right upper extremity with faint radial pulse. Soon after admission, patient’s respiratory status declined, requiring intubation and mechanical ventilation. She was also in septic shock, requiring two vasopressors for hemodynamic support. Blood cultures were positive for methicillin susceptible S. aureus. CT arteriogram of the chest showed a partially occlusive thrombus in the upper portion of the SVC extending to the origin of the right axillary vein. Intravenous unfractionated heparin was initiated and cardiology was consulted for thrombectomy, but patient was deemed too unstable to undergo any procedure. The next day, the patient developed acute limb ischemia which progressed to necrosis of the right upper extremity and chest wall, despite appropriate efforts to maintain perfusion. Over the next week, the patient underwent multiple surgical debridements, but healing remained complicated by persistent bacteremia and worsening myonecrosis. The patient remained critically ill, in refractory septic shock, and eventually had a cardiac arrest without return of spontaneous circulation. This case illustrates the importance of promptly recognizing and treating upper extremity DVT in order to prevent devastating complications. Acute limb ischemia can be life threating, especially in cases such as ours where there were multiple factors impeding healing. Furthermore, there are very limited therapeutic options for a SVC thrombus. Early intervention with mechanical thrombectomy or catheter directed thrombolysis is the definitive treatment, but only performed in a few centers in Alabama, especially in a critically ill patient. It is very interesting that this patient developed such an extensive thrombus without any obvious risk factors - perhaps a malignancy or thrombophilia workup was missed? This abstract is funded by: None
Venkatesan et al. (2026) studied this question.