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Register Now. IV acyclovir was given for 21 days. Need for emergency treatment in subclavian vein effort thrombosis. Help Accessibility Careers. Definitive coverage of the tibial defect was obtained with a soleus myocutaneous flap and split-thickness skin graft. If ultrasonography is inconclusive, venography can be performed in the same setting as treatment Figure 3.
 
 

 

Paget-Schroetter Syndrome – PMC

 

In most patients, anticoagulation for 3 to 6 months following an episode of deep venous thrombosis such as PSS is reasonable. This can be achieved either via warfarin or direct oral anticoagulants DOAC. In the case of recurrent thrombosis after decompression surgery, thrombolysis and venography are usually attempted again with the maintenance of long-term anticoagulation therapy afterward. In some patients with PSS, chronic total occlusion of the subclavian vein may persist despite adequate decompression maneuvers.

Depending on the severity of the symptoms, venous reconstruction should be considered. This can be achieved with a bypass or jugular vein turndown procedure with or without medial claviculectomy.

Upper extremity swelling may be present in patients with lymphatic disorders or systemic conditions such as end-stage renal disease and congestive heart failure.

Upper extremity deep venous thrombosis can be seen with indwelling catheters as well. Anticoagulation with decompression is less successful than thrombolysis and decompression but still yields better results than anticoagulation alone.

Patients should be encouraged to adhere to all medication recommendations and have close follow up with all of their healthcare providers. Activity and lifestyle modification may reduce the risk of recurrent thrombosis.

Patients with hypercoagulable states should be made aware that they may need long-term anticoagulation. The diagnosis and management of PSS are best accomplished with an interprofessional team that consists of a primary care provider, sports medicine clinician, vascular surgeon, and radiologist. Patients with venous obstruction do need treatment or the arm will remain swollen and painful.

After anticoagulation, decompression of the thoracic outlet is often required. Most patients do have a good outcome with treatment but depending on the state of the subclavian vein, some degree of arm swelling may persist. Today, for some cases of PSS, endovascular therapy is available. Patient with bilateral first rib resection. Contributed by StatPearls. The right subclavian artery and surrounding structures.

Contributed by Gray’s Anatomy Public domain. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Affiliations 1 St. Dominic Hospital.

Continuing Education Activity Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet.

Introduction Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet. Etiology The subclavian vein travels in the proximity of the clavicle, first rib, anterior scalene, and subclavius muscles.

Epidemiology PSS is more commonly seen in younger patients in their 20s and 30s with a male to female ratio of Pathophysiology Repetitive strain from vigorous physical activity and compression of the subclavian vein from adjacent anatomic structures leads to venous injury and subsequent thrombosis.

History and Physical Patients may present with upper extremity swelling and pain. Evaluation A convenient non-invasive first test is ultrasonography of the upper extremities. Differential Diagnosis Upper extremity swelling may be present in patients with lymphatic disorders or systemic conditions such as end-stage renal disease and congestive heart failure.

Complications Pulmonary embolism. Deterrence and Patient Education Patients should be encouraged to adhere to all medication recommendations and have close follow up with all of their healthcare providers. Enhancing Healthcare Team Outcomes The diagnosis and management of PSS are best accomplished with an interprofessional team that consists of a primary care provider, sports medicine clinician, vascular surgeon, and radiologist.

Review Questions Access free multiple choice questions on this topic. Comment on this article. Figure Patient with bilateral first rib resection. Figure cervical rib on chest x-ray. Image courtesy S Bhimji MD.

Figure The right subclavian artery and surrounding structures. Figure Cervical rib. References 1. Turk Kardiyol Dern Ars. Kardiol Pol. On the centenary of the death of Sir James Paget and on the 50th anniversary of the naming of the syndrome]. The importance of thrombophilia in the treatment of Paget-Schroetter syndrome. Ann Vasc Surg. Sonographic evaluation of upper extremity deep venous thrombosis. J Ultrasound Med. Effort thrombosis in the elite throwing athlete.

Green R, Rosen R. The management of axillo-subclavianvenous thrombosis in the setting of thoracic outlet syndrome. In: Gloviczki P, ed. Handbook of Venous Disorders. Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects. Am J Hematol. Paget-Schroetter syndrome in a collegiate football player. Clin J Sport Med. Long-term sequelae of spontaneous axillary-subclavian venous thrombosis. Ann Intern Med. Changing concepts of deep venous thrombosis of the upper extremity: report of a series and review of the literature.

Hughes ES. Venous obstruction in the upper extremity. Br J Surg. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. Axillary vein thrombosis in a female backpacker: Paget-Schroetter syndrome. Can Assoc Radiol J. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome.

Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg.

McLaughlin C, Pompa A. Intermittent obstruction of the subclavian vein. Effort thrombosis in a young wrestler: a case report. J Bone Joint Surg Am. Initial experience with venous stents in exertional axillary-subclavian vein thrombosis. Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein Paget-Schroetter syndrome.

Molina JE. Need for emergency treatment in subclavian vein effort thrombosis. J Am Coll Surg. Upper extremity venous thrombosis: case report and literature review. Orthop Rev. Paget J. Clinical Lectures and Essays.

Roos DB. Congenital anomalies associated with thoracic outlet syndrome: anatomy, symptoms, diagnosis, and treatment. Roos DB, Edgar J. Poth lecture: thoracic outlet syndromes. Update Safran MR. Venous thoracic outlet compression and the paget-schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol. Natural history of major venous thrombosis of the upper extremity. Arch Surg. Using a right basilic vein approach, catheter-directed thrombolysis with tissue plasminogen activator was initiated.

After approximately 24 hours, his venogram showed resolution of thrombosis but the presence of a severe subclavian vein stenosis at the level of the first rib.

Percutaneous transluminal angioplasty PTA was attempted within the proximal subclavian vein with little effect Fig. He was discharged on therapeutic subcutaneous enoxaparin as a bridge to warfarin with a plan for an elective first rib resection FRR with scalenectomy in 3 weeks. Demonstrating complete occlusion of right subclavian and axillary veins arrows. Wire transverses occluded segment. First rib dashed lines. Venogram approximately 24 hours after successful thrombolysis.

Significant subclavian vein stenosis arrows at the level of the first rib dashed lines persists after initial attempts at percutaneous transluminal angioplasty.

He was discharged by postoperative day 2 with the plan to complete a 3-month course of anticoagulation therapy. Intraoperative venogram following first rib resection circle denotes area of rib resection and percutaneous transluminal angioplasty for residual stenosis. Although stenosis is not clearly visualized in this unsubtracted image, the presence of venous collaterals arrows may infer a residual stenosis. Just before his final follow-up 2 months post-FRR with intraoperative PTA , the patient complained of mild, intermittent arm swelling associated with pain that coincided with an increase in upper extremity activity.

Venography was devoid of thrombus, but showed restenosis unresponsive to serial PTA; therefore, a mm self-expanding bare metal stent was deployed across the stenotic region with restoration of flow Fig. He was continued on oral anticoagulation for an additional 2. At his 6-month follow-up, right upper extremity duplex ultrasound was negative for thrombus or wall thickening in the venous system, therefore warfarin was discontinued and he was transitioned to oral antiplatelet therapy aspirin 81 mg daily for 3 months.

Upper extremity deep vein thrombosis is an uncommon entity; although most of the thrombotic events occurring at this site are secondary to catheters, indwelling devices, and cancer, venous thoracic outlet syndrome VTOS is an important cause of primary thrombosis.

VTOS is caused by extrinsic compression of the subclavian vein between the anterior scalene muscle and the junction of the first rib, clavicle, and subclavius muscle. Delayed presentation is common as distal tributaries form in response to venous congestion from luminal compression and initial thrombus; acute symptoms are hypothesized to occur after propagation of the clot obstructs these distal collaterals.

This condition is often misdiagnosed or underdiagnosed; prompt recognition and treatment within 14 days of the acute thrombus is one of the most important predictors of outcome. Treatment algorithms are highly varied given the relative rarity of this disease and lack of quality-randomized controlled studies.

Most protocols are guided by single institutional reports, retrospective reviews, and expert opinion. One of the most commonly used operative algorithms was developed by Kunkel and Machleder in the s; this protocol included early thrombolysis and 3 months of anticoagulation before transaxillary FRR.

Conservative, selective surgical algorithms have been described. For example, Lee et al from Stanford University performed rib resection only on those patients that had recurrent or persistent symptoms, had ultrasound evidence of wall thickening, or had rethrombosis after the initial clot lysis. Furthermore, this need for FRR increased with younger age, a defining characteristic of the active duty population.

Not only are there disparities between surgical and nonsurgical algorithms as discussed above, but there is also a lack of consensus on the appropriate timing of FRR, PTA, and stenting. Repeat venography was obtained at approximately 10 days postoperatively; if residual stenosis was present and not responsive to PTA, stenting was performed.

Standard postintervention oral anticoagulation duration was for 3 months. This one-stage operation was hypothesized to decrease the risk of rethrombosis and need for stent placement in the postoperative period. The results of the venogram dictated additional management anticoagulation plus PTA or anticoagulation alone. Other literature suggest that PTA may be used before or after surgical decompression, whereas stent placement is typically reserved for residual stenosis, not responsive to PTA, only after the extrinsic compression has been removed.

Reviewing literature for other military case reports, FRR was delayed 8 months after presentation, 17 there was no mention of time course to FRR, 18 , 19 or patients received conservative, nonsurgical management only. Presurgical intervention beyond thrombolysis providing immediate symptom relief in the acute phase may have little impact on the long-term patency and recovery as long as FRR is performed promptly. Therefore, we could have considered thrombolysis alone followed by FRR during the initial hospitalization to reduce his total course of treatment.

Predecompression PTA may be a superfluous attempt as the extrinsic forces on the vein have not been removed. More importantly, it may be difficult to ascertain the final disposition of the treated vein following surgery as this area can be challenging to duplex and the patient may not be active enough to induce symptoms of venous obstruction related to residual intrinsic defects.

Reported symptomatology and physical examination alone have been shown to be an inaccurate means of determining venous patency. Therefore, accurate and early postoperative imaging is key; routine venography, as described by the Johns Hopkins series, has been justified in the absence of symptoms and has been proclaimed as best practice for long-term success.

Although, we did perform a routine ultrasound at his 6-month follow-up to support discontinuation of oral anticoagulation, we should additionally consider a routine ultrasound at the month mark. Diagnosis and treatment of VTOS is a clinical challenge. Primary care providers in the Fleet must maintain a high index of suspicion when a patient presents with upper extremity complaints related to recent vigorous exercise.

To avoid long-term disability in this unique patient population, recognition and prompt referral for specialized surgical intervention is paramount. Immediate or early decompression with FRR should be considered as this has shown to reduce the risk of pulmonary embolism, rethrombosis, and the debilitating sequelae of post-thrombotic syndrome. Routine ultrasound examination should be performed in the asymptomatic patient up to 12 months postsurgery. VG Katana and JS Weiss had full access to all the data in the study and take responsibility for the integrity of the data, and VG Katana and JS Weiss interpreted the data and take responsibility for the accuracy of the data analysis.

Drafting of the manuscript and critical revision of the manuscript for important intellectual content was performed by VG Katana and JS Weiss.

 
 

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