Paget-Schroetter syndrome

Background

• Thrombosis of the axillary and/or subclavian vein associated with repetitive movements of the upper extremity, such as those with sporting events (e.g. swimming, wrestling, etc)
  • Usually affects dominant arm
• May be acute, subacute or chronic

Clinical Features

• Arm swelling, pain
• Redness of the upper extremity
• Dilated, visible veins around the shoulder (Urschel’s sign)
• Most patients report a precipitating event, generally sports-related arm exertion

Differential Diagnosis

Upper extremity swelling

• Cellulitis
• Deep venous thrombosis
  • Paget-Schroetter syndrome
• Lymphatic obstruction
• Necrotizing fasciitis
• Superficial thrombophlebitis
• SVC Syndrome
• Thoracic outlet obstruction/Pancoast tumor

Evaluation

• 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

1. Anticoagulation
   • LMWH, Fondaparinux, Unfractionated Heparin
     • Choice depends on further plans for intervention and disposition
     • Bridge to Coumadin
2. Thrombolysis
   • Catheter directed infusion of alteplase or urokinase
   • For moderate to severe cases
3. 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

• Deep venous thrombosis
• DVT ultrasound