Paget-Schroetter syndrome

Background

Paget-Schroetter Syndrome- axillary or subclavian vein thrombosis associated with strenuous and repetitive activity of the upper extremities affecting usually young athletic people

Clinical Features

--upper extremity swelling and discomfort, usually unilateral

--redness of the upper extremity

--dilated visible veins around the shoulder (Urschel’s sign)

--cyanosis

--may have a discrete precipitating event- usually sports-related arm exertion

--may be acute, subacute or chronic

Differential Diagnosis

--Thoracic outlet obstruction/Pancoast tumor

--lymphatic obstruction

--SVC syndrome

--cellulitis

--necrotizing fasciitis

Workup

--CBC, CMP, coags

--consider D-dimer

--Chest X-ray to rule out anatomic abnormalities or lung masses that might cause thoracic outlet obstruction

--Ultrasound with color Doppler- preferred initial test (sensitivity 78-100%, specificity 82-100%)

--MRI venography (noninvasive, but expensive and limited availability)

--Gold standard- contrast venography (use when ultrasound findings are equivocal but still have high clinical suspicion)

Management

--anticoagulation- LMWH, Fondaparinux, unfractionated heparin- choice depends on further plans for intervention and disposition; bridging to Coumadin

--thrombolysis- catheter directed infusion of alteplase or urokinase (for moderate to severe cases)

--surgical decompression (for moderate to severe cases)

Disposition

Depends on the severity of symptoms and the acuity of presentation

--mild/intermittent/chronic (>2weeks) symptoms- outpatient management with LMWH bridging to Coumadin

--severe/acute presentation- admit, consult vascular surgery for thrombectomy or thrombolysis

See Also

Ultrasound: DVT DVT (Deep Venous Thrombosis)

Sources

1. Alla V, Ntarajan N, Kaushik M, Warrier R, Nair C. Paget-Schroetter Syndrome: Review of Pathogenesis and Treatment of Effort Thrombosis. Western Journal of Emergency Medicine, Vol XI, No 4, 2010, p 358

2. Chin E, Zimmerman P, Grant E. Sonographic Evaluation of Upper Extremity DVT. J Ultrasound Med, 2005; 24:829-838

3. Goshima K, White M. Overview of Thoracic Outlet Syndromes. UpToDate, 2012

4. Goshima K. Primary (spontaneous) Upper Extremity Deep Venous Thrombosis. UpToDate, 2013