Modern approaches in the treatment of patients with Paget-Schretter syndrome

Goal. Consider the management of patients with effort thrombosis (Paget-Schretter syndrome).The article presents the modern vision of the problem of effort thrombosis. This review is aimed at describing the epidemiology, pathophysiology, diagnosis and treatment of patients with Paget-Schretter syndrome. SPS occurs spontaneously, as a rule, in young, healthy and active patients aged 20-30 years after strenuous physical activity. The ratio of men and women is 2:1, recently there has been a growing trend among women. The main complaints of patients with SPS include swelling of the affected limb, discomfort when moving the affected arm, pain and heaviness when trying to raise the arm up. When examining these patients, attention is paid to hyperemia of the skin or their cyanotic nature, pasty limbs, as well as an enhanced venous pattern on the shoulder, the so-called Arshel sign. The diagnosis is based on the data of anamnesis, physical examination, the “gold standard of diagnostics” – ultrasound examination of veins, the sensitivity and specificity of which is 70-100%. The first step in the diagnosis can be the evaluation of the D-dimer, with its negative values, the SPSH is rejected. With an obvious clinic and controversial results of serial ultrasound examinations, other imaging methods are used, such as computed contrast tomography, magnetic resonance imaging, the diagnostic value of which is especially significant in occlusive venous thrombosis.SPS differs not only from DVT of the lower extremities, but also from secondary DVT of the upper extremities, which determines the peculiarities of management of this category of patients, including surgical treatment aimed at preventing subclavian vein compression in the future. The article summarizes the experience in the management of patients with blood thrombosis.

Percutaneous thrombectomy in the management of early rethrombosis in venous thoracic outlet syndrome: two case reports

Background Venous thoracic outlet syndrome resulting in the upper limb deep venous thrombosis is known as Paget–Schroetter syndrome or effort thrombosis. A general treatment algorithm includes catheter-directed thrombolysis followed by surgical thoracic outlet decompression. There are limited data regarding endovascular treatment of rethrombosis presenting early after the surgery. Case presentation Two cases of early rethrombosis successfully treated with percutaneous mechanical thrombectomy by two different techniques are described. In both cases, rethrombosis was diagnosed soon after thrombolysis and first rib resection with scalenectomy. After 12 months, both patients remain symptom-free, with patent subclavian veins confirmed by duplex ultrasonography. Conclusion Percutaneous mechanical thrombectomy devices may offer a safe treatment option for patients with recurrent thrombosis after thoracic outlet surgery, even when thrombolytic therapy is contraindicated.

Successful Use of Apixaban for Paget-Schroetter Syndrome in a Pediatric Patient

Paget-Schroetter syndrome (PSS) is a rare syndrome that typically develops in young, healthy males subjected to repetitive overhead motions resulting in compression and thrombosis of the subclavian vein. This “effort thrombosis” typically occurs acutely in patients with specific anatomic variations within the thoracic outlet and is treated by a combination of surgical and pharmacologic interventions. There is a paucity of literature regarding this syndrome, particularly surrounding pharmacotherapy, and in the treatment of pediatric patients. This case report documents the pharmacologic treatment of a 17-year-old, male, baseball player with confirmed PSS. Apixaban was selected as the anticoagulant therapy of choice following the determination of its safety and anticipated efficacy for this pediatric patient. Upon admission, anticoagulation was initiated with intravenous heparin and transitioned to warfarin for 1 dose. On day 2, the patient was discharged with apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily. One week later, he underwent catheter-directed thrombectomy, followed by thoracic outlet decompression with resection of the first rib. Apixaban therapy was continued for 10 weeks after the procedure to diminish the risk of any further thrombotic events. This pediatric patient with PSS was successfully treated with apixaban in conjunction with surgical management. Treatment with apixaban resulted in continued resolution of thrombus after follow-up, with no complications reported thereafter. Further research is needed to definitively determine the safety and efficacy of apixaban for the use of pediatric anticoagulation, particularly in upper extremity deep vein thrombosis.

Percutaneous Thrombectomy in the Management of Early Rethrombosis in Venous Thoracic Outlet Syndrome: Two Case Reports

BackgroundVenous thoracic outlet syndrome resulting in the upper limb deep venous thrombosis is known as Paget–Schroetter syndrome or effort thrombosis. A general treatment algorithm includes catheter-directed thrombolysis followed by surgical thoracic outlet decompression. There are limited data regarding endovascular treatment of rethrombosis presenting early after the surgery.Case presentationTwo cases of early rethrombosis successfully treated with percutaneous mechanical thrombectomy by two different techniques are described. In both cases, rethrombosis was diagnosed soon after thrombolysis and first rib resection with scalenectomy. After 6 months, both patients remain symptom-free, with patent subclavian veins confirmed by duplex ultrasonography. ConclusionPercutaneous mechanical thrombectomy devices may offer a safe treatment option for patients with recurrent thrombosis after thoracic outlet surgery, even when thrombolytic therapy is contraindicated.

Primary upper extremity deep vein thrombosis (effort thrombosis)

Primary spontaneous upper extremity deep vein thrombosis is characterised by thrombosis within deep veins draining the upper extremity due to anatomical abnormalities of the thoracic outlet causing axillosubclavian compression and subsequent thrombosis. It is an uncommon condition that typically presents with unilateral arm swelling in a young male following vigorous upper extremity activity. The diagnosis of this condition is usually made by Doppler ultrasound, but other investigations are mandatory to exclude the secondary causes of upper extremity DVT. Different treatment options are available including anticoagulation, thrombolysis, and surgery. We report the case of a young healthy male with athletic physique who presented with pain and swelling of his dominant arm after weightlifting in the gym.

Paget-Schroetter Syndrome in a Young Female

Paget-Schroetter syndrome or effort thrombosis is a relatively rare primary spontaneous thrombosis of upper extremity deep veins secondary to entrapment of axillary subclavian veins from an abnormality of the thoracic outlet. It is commonly seen in young adults who lift heavy weights or strenuous use of the upper extremities during athletic activities. Repetitive microtrauma to the subclavian vein secondary to narrow costoclavicular space and strenuous activities leads to intimal layer inflammation, hypertrophy, fibrosis, and coagulation cascade activation. Management of Paget-Schroetter syndrome differs from the venous thrombosis of the lower extremity as treatment includes anticoagulation, thrombolysis, and surgical decompression. Early recognition and timely management are required to prevent significant disability from post-thrombotic syndrome and long-term morbidity from recurrent thromboembolism and pulmonary embolism. Internists and emergency physicians should be aware of the disease’s presentation, treatment options, and early referral to vascular surgeons since prompt initiation of appropriate treatment will have better outcomes than delayed treatment. We discussed a case of a 31-year-old female who lifts heavyweight at work, presented with right arm swelling and pain for 2 weeks, and diagnosed with axillary subclavian vein thrombosis secondary to thoracic outlet obstruction. She received a high-dose heparin drip followed by catheter-directed thrombolysis and underwent surgical decompression of axillary subclavian vein via resection of the first rib, subclavius muscle resection, partial anterior scalenectomy, and venolysis. In our review of the literature, randomized controlled studies lack the efficacy and safety of surgical decompression. However, the results are promising based on accumulated experience from vascular surgery experts and small case series. Extensive studies are needed further to delineate the protocol for the management of Paget-Schroetter syndrome.