We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Paget-Schroetter syndrome
From WikEM
Contents
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
- Anticoagulation
- LMWH, Fondaparinux, Unfractionated Heparin
- Choice depends on further plans for intervention and disposition
- Bridge to Coumadin
- LMWH, Fondaparinux, Unfractionated Heparin
- 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
- Mild/intermittent/chronic (>2weeks) symptoms
See Also
References
- 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
