Paget-Schroetter syndrome
Background
- 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
Sources
- 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
- Chin E, Zimmerman P, Grant E. Sonographic Evaluation of Upper Extremity DVT. J Ultrasound Med, 2005; 24:829-838
- Goshima K, White M. Overview of Thoracic Outlet Syndromes. UpToDate, 2012
- Goshima K. Primary (spontaneous) Upper Extremity Deep Venous Thrombosis. UpToDate, 2013