Paget-Schroetter syndrome: Difference between revisions

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==Background==
==Background==
Paget-Schroetter Syndrome- axillary or subclavian vein thrombosis associated with strenuous and repetitive activity of the upper extremities affecting usually young athletic people
*[[Thromboembolism|Thrombosis]] of the axillary and/or subclavian vein associated with repetitive movements of the upper extremity, such as those with sporting events (e.g. swimming, wrestling, etc)<ref name="Alla">Alla, V. M., Natarajan, N., Kaushik, M., Warrier, R., & Nair, C. K. (2010). Paget-Schroetter Syndrome: Review of Pathogenesis and Treatment of Effort Thrombosis. Western Journal of Emergency Medicine, 11(4), 358–362.</ref>
*Usually affects dominant arm
*May be acute, subacute or chronic
 
==Clinical Features==
==Clinical Features==
--upper extremity swelling and discomfort, usually unilateral
*Arm swelling, pain
 
*[[rash|Redness]] of the upper extremity
--redness of the upper extremity
*Dilated, visible veins around the shoulder (Urschel’s sign)
 
*Most patients report a precipitating event, generally sports-related arm exertion<ref name="Alla" />
--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 ==
==Differential Diagnosis==
--Thoracic outlet obstruction/Pancoast tumor
{{Upper extremity swelling DDX}}


--lymphatic obstruction
==Evaluation==
*[[Ultrasound: DVT|Doppler ultrasound]] is preferred test
*CTV or MRV have higher sensitivity/specificity if continued clinical concern
*May also consider:
**[[CXR]] to evaluate for causes of [[thoracic outlet obstruction]]
**Laboratory testing


--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==
==Management==
--anticoagulation- LMWH, Fondaparinux, unfractionated heparin- choice depends on further plans for intervention and disposition; bridging to Coumadin
[[File:PSS.jpg|thumb|Paget-Schroetter syndrome treatment]]
 
*Catheter-directed [[thrombolysis]] is first-line treatment for acute disease (<2-6 weeks duration)<ref name="Alla" />
--thrombolysis- catheter directed infusion of alteplase or urokinase
*Consider surgical thoracic outlet decompression (TOD) for chronic disease or failure of catheter-directed thrombolysis
 
*'''Anticoagulation alone is not recommended due to high rates of morbidity'''
--surgical decompression


==Disposition==
==Disposition==
Depends on the severity of symptoms and the acuity of presentation
*Admit
 
--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==
==See Also==
[[Ultrasound: DVT]]
*[[Deep venous thrombosis]]
[[DVT (Deep Venous Thrombosis)]]
*[[DVT ultrasound]]
 
==Sources==
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
==References==
<references/>


4.  Goshima K. Primary (spontaneous) Upper Extremity Deep Venous Thrombosis. UpToDate, 2013
[[Category:Heme/Onc]]

Latest revision as of 17:13, 1 October 2019

Background

  • Thrombosis of the axillary and/or subclavian vein associated with repetitive movements of the upper extremity, such as those with sporting events (e.g. swimming, wrestling, etc)[1]
  • Usually affects dominant arm
  • May be acute, subacute or chronic

Clinical Features

  • Arm swelling, pain
  • Redness of the upper extremity
  • Dilated, visible veins around the shoulder (Urschel’s sign)
  • Most patients report a precipitating event, generally sports-related arm exertion[1]

Differential Diagnosis

Upper extremity swelling

Evaluation

Management

Paget-Schroetter syndrome treatment
  • Catheter-directed thrombolysis is first-line treatment for acute disease (<2-6 weeks duration)[1]
  • Consider surgical thoracic outlet decompression (TOD) for chronic disease or failure of catheter-directed thrombolysis
  • Anticoagulation alone is not recommended due to high rates of morbidity

Disposition

  • Admit

See Also

References

  1. ↑ 1.0 1.1 1.2 Alla, V. M., Natarajan, N., Kaushik, M., Warrier, R., & Nair, C. K. (2010). Paget-Schroetter Syndrome: Review of Pathogenesis and Treatment of Effort Thrombosis. Western Journal of Emergency Medicine, 11(4), 358–362.
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