Current management of Paget-Schroetter syndrome in the UK

Diagnosing Paget-Schroetter Syndrome Using Point of Care Ultrasound (POCUS)

Paget-Schroetter Syndrome, or effort thrombosis, is a relatively rare disorder. It refers to axillary-subclavian vein thrombosis (ASVT) that is associated with strenuous and repetitive activity of the upper extremities 1. Anatomical abnormalities at the thoracic outlet and repetitive trauma to the endothelium of the subclavian vein are key factors in its initiation and progression. Doppler ultrasonography is the preferred initial test, but contrast venography is the gold standard for diagnosis 1, 2. Early diagnosis coupled with a multimodal treatment strategy is crucial for optimal outcomes. We present a case of a 21-year-old male in which point of care ultrasound (POCUS) expedited the diagnosis and subsequent early treatment of right subclavian vein thrombosis. He presented to our Emergency Department with acute swelling, pain and erythema of his right upper limb. He was promptly diagnosed to have thrombotic occlusion of the right subclavian vein using POCUS in our Emergency Department.

The infraclavicular approach for Paget-Schroetter syndrome

Introduction Paget-Schroetter syndrome is a rare effort thrombosis of the axillary-subclavian vein, mainly occurring in young male patients. Current management involves immediate catheter directed thrombolysis, followed by surgical decompression of the subclavian vein. This has been invariably performed using a transaxillary or supraclavicular approach. However, the subclavian vein crosses the first rib anteriorly just behind the manubrium and can also be accessed via an infraclavicular incision. Methods MEDLINE® and Embase™ were searched for all studies on outcomes in patients undergoing infraclavicular first rib resection for treatment of Paget-Schroetter syndrome. Measured outcomes included freedom from reintervention, secondary patency and symptom resolution. Studies on neurogenic, arterial and iatrogenic venous thoracic outlet syndrome were not included. Findings Six studies (involving 268 patients) were eligible. The overall secondary venous patency rate was 98.5%. There was freedom from reintervention in 89.9% of cases and among those patients with reocclusion, 84.0% had chronic thrombosis (symptom duration >14 days), with 76.2% having a venous segment stenosis of >2cm. Only 3 of the 27 patients remained occluded despite reintervention. The infraclavicular approach provides excellent exposure to the subclavian vein and allows reconstruction when required. Moreover, this approach enables complete resection of the extrinsic compression that precipitated the initial thrombotic event, with excellent long-term patency rates. In conclusion, the infraclavicular route may have significant advantages compared with the transaxillary or supraclavicular approaches for successful and durable treatment of Paget-Schroetter syndrome.

Paget-Schroetter syndrome complicated by an incidental pulmonary embolism

A young man presented with the severe right upper limb swelling following a heavy weight lifting that was thought to be caused by a biceps tendon rupture. However, subsequent investigations confirmed the diagnosis of Paget-Schroetter syndrome that was associated with an incidental pulmonary embolism. The patient underwent a successful thrombolysis followed by a surgical thoracic outlet decompression. Overall, the patient has made a good recovery.

Endovascular Management of Paget-Schroetter Syndrome

Spontaneous thrombosis of the axillary and subclavian venous segments in young, healthy adults (effort thrombosis or Paget-Schroetter syndrome) is a rare but potentially disabling affliction. The diagnosis should be suspected in any young patient presenting with unilateral arm swelling. Typically, the dominant arm is affected, and frequent, repetitive arm use is a common component of the patients' history. Although the diagnosis can often be confirmed with a venous duplex evaluation, the central location of the venous abnormality occasionally mandates cross-sectional imaging or contrast venography to confirm the diagnosis. The underlying pathophysiology of this disorder is felt to be repetitive venous trauma owing to arm motion in the narrow anatomic space between the clavicle and first rib. The treatment of Paget-Schroetter syndrome is controversial and varies according to individual, institutional, and regional preferences. In general, the trend is toward more aggressive endovascular treatment. Prompt anticoagulation is generally accepted as the minimal treatment offered. Catheter-directed thrombolysis has also acquired a prominent role in reestablishing venous patency. The importance of relieving the anatomic compression of the subclavian vein by first rib resection remains controversial, with some experts advocating surgical intervention in all affected patients, whereas others perform this procedure selectively in cases of persistent venous stenosis or ongoing symptoms. Angioplasty with or without stenting is generally discouraged in the absence of anatomic decompression but may play an adjunctive role in patients undergoing first rib resection.

Paget-Schroetter syndrome: A review and Algorithm (WASPS-IR)

Venous compression syndromes are rare and occur due to the entrapment of vein(s) in confined anatomical spaces bounded by osseous and non-osseous structures. Here we present a review of Paget-Schroetter Syndrome, an important cause of upper extremity of deep vein thrombosis, its associated clinical and radiological findings as well as treatment options.

Routine Venography Following Transaxillary First Rib Resection and Scalenectomy (FRRS) for Chronic Subclavian Vein Thrombosis Ensures Excellent Outcomes and Vein Patency

To assess the role of postoperative venography in patients treated with first rib resection and scalenectomy (FRRS) for effort thrombosis, a retrospective review was done to evaluate long-term venous patency in 84 patients treated at the Johns Hopkins Medical Institutions. Patients undergo venography 2 weeks postoperatively. If there is >50% stenosis, the subclavian vein is dilated and the patient receives anticoagulation. If the vein is occluded, patients are maintained on anticoagulation. Of the 85 patients, 21 patients had patent veins, 47 patients had stenotic veins, and 16 patients had chronically occluded veins. In follow-up, symptomatic restenosis was seen in 3 patients and those veins were redilated. Two other patients had late occlusions at 23 and 63 months and received anticoagulation and redilatation, respectively. Using venography to guide postoperative management, 79 of 84 patients had patent veins many years postoperatively. Long-term patency, as seen by duplex scan, was achieved in nearly all patients using this protocol.

Paget-Schroetter syndrome treated with cutting-balloon angioplasty

Here, a case of Paget-Schroetter Syndrome in a 25-year-old guitar player is reported. After thrombolysis, conventional angioplasty failed to dilate the underlying subclavian stenosis both before and after first-rib excision with scalenus anterior and medius division. For the third attempt at angioplasty, a cutting balloon was used, which immediately produced a good result. Venography at 4-year follow-up showed no restenosis and no functional deficit. This case report demonstrates that cutting-balloon angioplasty may be considered when conventional balloon fails and may have greater durability than conventional balloon angioplasty in the treatment of Paget-Schroetter syndrome.

Paget-Schroetter syndrome: the importance of urgent referral and appropriate management

The authors present the case of a young healthy male who was admitted with a case of acute primary subclavian vein thrombosis, otherwise known as Paget-Schroetter syndrome. The patient was successfully treated by catheter directed thrombolysis using a Trellis device and thoracic outlet decompression following prompt referral to the vascular team. The case highlights importance of early referral in the prevention of the long-term sequelae which can occur as a result of this rare condition.

Paget-Schroetter syndrome: an uncommon cause of pulmonary embolic disease

Paget-Schroetter syndrome is an uncommon cause of pulmonary thromboembolic disease that should be suspected in young patients in whom effort-related subclavian vein thrombosis should be investigated. Our case illustrates the pivotal role of imaging and the different modalities available to establish such a diagnosis.

Clinical Usefulness of Hybrid Intervention for the Treatment of Primary Thrombosis of Axillary-subclavian Vein

Untreated symptomatic patients with Paget-Schroetter syndrome can suffer chronic disability due to venous obstruction, with arm swelling, pain, and early exercise fatigue. Although systemic or catheter-directed thrombolysis followed by anticoagulation and surgical intervention is recommended, there is no definite consensus about treatment. Here, we report the clinical usefulness of hybrid intervention with a combination of thrombectomy, thrombo-aspiration and balloon PTA, which has not been reported previously for this condition. These procedures were successful, and the patient has been free of symptoms for 6 years.

Diagnosis and Management of Subclavian Vein Thrombosis: Three Case Reports and Review of Literature

Axillosubclavian vein thrombosis is seen relatively infrequently in clinical practice when compared with lower limb deep-venous thrombosis; however, it is a condition that can result in significant morbidity if managed suboptimally. A multimodal treatment approach has been increasingly adopted with thrombolysis and/or thoracic outlet decompression being favored over anticoagulation alone, although the evidence base to support this approach is limited. In all, 3 cases are reported, which highlight numerous pertinent issues relating to the diagnostic and therapeutic options available.

First rib resection in thoracic outlet syndrome

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.

Effort thrombosis of the upper extremity in a young sportsman: Paget-Schroetter syndrome

Paget-Schroetter syndrome is the spontaneous thrombosis of the axillary/subclavian vein. A 16-year-old male presented with acute onset of right upper limb swelling after vigorous weight training. A venogram confirmed the diagnosis of Paget-Schroetter syndrome. He was started on intravenous thrombolytics followed by oral anticoagulation therapy. His symptoms resolved and he was symptom free at six-month follow-up. Thrombolytics and anticoagulation is the most widely accepted first-line therapy for this syndrome. Defining any anatomical anomaly as the predisposing factor in this condition is essential in the selection of which patients will benefit from thoracic outlet decompression.

Exercise-induced deep vein thrombosis of the upper extremity. 1. Literature review

Paget-Schroetter syndrome or effort-related upper extremity deep vein thrombosis is a rare condition that usually afflicts young healthy individuals, most commonly males. The cause is multifactorial but almost always involves extrinsic compression of the subclavian vein at the thoracic inlet, causing venous stenosis from repetitive trauma. The diagnosis of this condition may be difficult, and its delay may contribute to potential complications including thrombosis progression, pulmonary embolism, thrombosis recurrence, and post-thrombotic syndrome. Similarly, the best therapeutic option has not been established and in the lack of evidence-based guidelines, treatment may be extremely challenging especially in children, in whom long-term complications can be particularly disabling.

Exercise-induced deep vein thrombosis of the upper extremity. 2. A case series in children

Upper-extremity deep venous thrombosis (UEDVT) is an increasingly important clinical problem in children. These events are classified as primary or secondary, with the latter being the most common and usually associated with the presence of a central venous line. Among primary UEDVT, the so-called Paget-Schroetter syndrome, effort-related or exercise-induced upper-extremity thrombotic event represents an extremely rare finding that has never been described in a pediatric series. The objective of the second part of this two-part article is to report the first pediatric series in a group of adolescents with this condition from a single center, describing their clinical features, management, and outcome. A retrospective chart review of 6 patients seen between December 2003 and April 2005 was conducted, with a median follow-up of 9 months (range 2-17). Four females and two males, all Caucasian, were enrolled with a median age of 16 years (range 14-17). In all cases, strenuous exercise was present in the month preceding diagnosis and mild trauma was present in only one case (weight lifting). At presentation, all patients had objective swelling of the affected limb for a median of 4 days (range 2-14), and 4 patients had UEDVT of the dominant arm. Thrombophilia investigation revealed that 50% had a combined prothrombotic state at presentation, and all patients were/are being treated with anticoagulation for 6 months (low-molecular-weight heparin followed by warfarin). Continuation of the initial symptoms was present in all cases but one at the 3-month clinic follow-up (last case has yet to reach 3 months of follow-up), and residual moderate to severe postthrombotic syndrome was present in all 3 cases followed for more than 12 months. Of those 3 patients followed for more than 1 year, 2 patients recurred despite having complete resolution of the thrombus after 6 months of anticoagulation, and the third patient underwent surgery with clinical improvement. Adolescents with UEDVT treated only with anticoagulation seem to have a poor outcome.

Paget-Schroetter syndrome and pulmonary thromboembolism: clinical follow-up over 5 years

A scaffold constructor lost consciousness at work, leading to emergency admission to our hospital. He had noted gradual worsening of exertional dyspnea over the previous 1 month. Chest radiography showed localized oligemia and enlarged hilar vessels. Pulmonary perfusion scintigraphy confirmed the existence of multiple perfusion defects, so a diagnosis of pulmonary thromboembolism was made. Upper and lower limb venography disclosed interruption of the right subclavian vein (so-called Paget-Schroetter syndrome). However, there was no difference in appearance between the right and left upper extremities. Five years after starting anticoagulant therapy, his symptoms have resolved, but serial perfusion scintigraphy and upper extremity venography revealed the persistence of abnormalities. In patients with pulmonary thromboembolism, lifestyle factors (especially heavy manual labor) should be considered and the possibility of subclavian vein thrombosis should be kept in mind.