Upper Extremity Deep Vein Occlusion Attributable to Metastatic Renal Cell Carcinoma

Abstract

Venous occlusion typically is caused by thrombosis, as is demonstrated by non-compressibility of the suspected vessel on duplex ultrasound. We report an unusual case of extensive bilateral upper-extremity and jugular venous obstruction caused by tumor thrombus. A 59-year-old man with a history of metastatic renal cell carcinoma presented to the vascular laboratory with right upper-extremity swelling. Our study revealed atypical masses of mixed echogenicity within the right and left internal jugular veins. At one location, the mass appeared to enter the left internal jugular vein from the surrounding tissue. Spectral Doppler within the mass demonstrated arterial vascularity. There also was Doppler evidence of occlusion of the right subclavian vein. The unusual appearance of the mass, in conjunction with the clinical history, prompted further investigation. Magnetic resonance venography confirmed the finding of extensive thrombosis of bilateral internal jugular veins, bilateral innominate veins, and the right subclavian vein. The patient underwent venography, transvenous biopsy, and stenting of the left innominate vein. Biopsy of the left innominate vein thrombus revealed renal cell carcinoma, which was consistent with the patient's known malignancy. We report an unusual cause of upper-extremity deep vein obstruction caused by metastatic cancer. Although renal cell carcinoma is associated with inferior vena cava extension and lower-extremity deep vein thrombosis, this is the first known case of bilateral upper-extremity deep vein thrombosis caused by this malignancy.