A 36‐year‐old healthy male presented with a 6‐hour onset of pain, swelling, and purplish discoloration of the left upper extremity after lifting weights at the gym. He denied any trauma to the shoulder or left upper extremity. On physical examination, purplish discoloration and pit‐Ting edema of the left upper extremity were noted. There was diffuse tenderness but no crepitation. Radial and brachial pulses were 2+ and symmetric bilaterally. Ultrasound duplex showed occlusive clot in the proximal and mid subclavian vein with patent internal jugular vein. CT chest showed evidence of significant stenosis at the medical aspect of left subclavian vein suggestive of thoracic outlet syndrome. No masses or cervical ribs were noted. He was started on unfractionated heparin. Venogram with The patient's arm abducted revealed occlusion of the left subclavian vein at a point where it trails behind clavicle. Patient underwent catheter guided thrombolysis, which was unsuccessful in relieving the stenosis. He then underwent angioplasty with good flow after the procedure. Patient was discharged home on warfarin, and first rib resection was done after 4 weeks. Anticoagulation was continued for 3 months after surgery.
Paget‐Schroetter syndrome (PSS), also known as “effort“‐induced upper‐extremity DVT (UEDVT), encompasses approximately 30% of cases of UEDVT. As the name implies, it typically presents after vigorous activity involving arm abduction, cervical extension, and shoulder depression, especially in the presence of a mechanical abnormality at the thoracic inlet where the subclavian vein (SCV) is compressed between a hyper‐trophied anterior scalene muscle and the first rib. It is postulated that microtrauma to the venous vessel wall activates the coagulation cascade. Repetitive venous compression can result in fibrous tissue formation that permanently constricts the vein. The most common clinical features of this syndrome are arm swelling and pain. These manifestations may be confused with cellulitis and thus patients may be inappropriately treated with antibiotics. With chronic obstruction, spider nevi and engorgement of subcutaneous veins can be seen on anterior chest wall. Contrast venogram is the diagnostic procedure of choice. The rationale in favor of expeditious catheter‐directed thrombolysis as the adopted therapeutic strategy is that young healthy affected individuals are at high risk of developing postthrombolic syndrome if treated with anticoagulation alone. Surgical resection of a cervical or the first rib is often required to prevent recurrence.
Paget‐Schroetter syndrome should be considered in differential diagnosis in patients who are active and present with painful swelling of the involved upper extremity. Hospitalist must be aware of this potentially disabling condition as early intervention is effective in relieving the clot burden and preventing potential complications such as pulmonary embolus and postthrombolic syndrome.
T. Hamieh, none; M. Saha, none; K. Koduru, none