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
• Superficial thrombophlebitis

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

• DVT ultrasound
• DVT (Deep Venous Thrombosis)

References

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

Authors

Ross Donaldson