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