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Essential Features

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  • • Axillary-subclavian thrombosis: 3 etiologies

    • 1. Paget-Schroetter syndrome: Also called "effort thrombosis"

      –Results from intermittent obstruction of vein during repetitive arm/shoulder movements

      –Subclavian vein compressed between first rib, anterior scalene muscle, and clavicle

      2. Primary subclavian venous thrombosis occurs in patients with hypercoagulable states

      3. Secondary subclavian venous thrombosis results from venous injury (central lines, external trauma, pacemaker wires)

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Epidemiology

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  • • Thrombosis of axillary/subclavian vein < 5% of DVT; 12% result in PE

    • Paget-Schroetter affects more men than women (4:1); 56% are hypercoaguable

    • –Occurs in healthy young athletes and persons who perform manual labor

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Clinical Findings

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Symptoms and Signs

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Paget-Schroetter
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  • • Repetitive arm activity and exercise

    • Significant superficial venous distention in arm/shoulder

    • Aching pain

    • Cyanosis of chest wall, axilla, shoulder, and arm

    • Other symptoms of thoracic outlet syndrome may be present (see Thoracic Outlet Syndrome)

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Subclavian Venous Thrombosis
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  • • Edematous, cyanotic arm, hand

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Imaging Findings

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  • • Duplex US of upper extremity

    • Venography + thrombolysis considered if duplex US is abnormal (positional venography with arm abducted 120 degrees)

    Chest film: Exclude cervical rib

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Diagnostic Considerations

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  • • Evaluate for other evidence of hypercoagulability

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Work-up

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  • • Duplex US

    • Possible venogram

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Treatment and Management

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  • • Remove indwelling central lines/ pacemakers

    • Elevate arm, hydrate with IV fluid

    • Thrombolysis

    • –If vein stenotic, perform angioplasty on vein segment

    • Vein compression with large collaterals suggests venous thoracic outlet syndrome and necessitates early operation

    • Surgical thoracic outlet decompression

    • –Resect anterior scalene muscle

      –First rib resection

      –Venoplasty

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Surgery

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Indications
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  • • Venous thoracic outlet syndrome

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Complications

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  • • Without surgery, venous thoracic outlet syndrome carries a 35–65% risk of rethrombosis

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Prognosis

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  • • Excellent if treated early

    • If thrombosis exists > 3 mos, it does not respond to therapy and may cause significant long-term disability

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Resources

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  • • Urschel HC et al. Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg. 2000;69:1663.

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Essential Features

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  • Virchow's triad: Stasis, vascular injury, hypercoagulability

    • Stasis: Venous insufficiency, heart failure, prolonged bed rest/plane travel

      Endothelial injury: Direct trauma, chemotherapy infusion, previous DVT, phlebitis, operative trauma all increase release of tissue factor increasing thrombin and decreasing fibrinolysis

      Hypercoagulability: Malignancy, protein C or S deficiency, disseminated intravascular coagulation (DIC), liver failure, elevated homocysteine, factor V Leiden, prothrombin gene variant, paroxysmal nocturnal hemoglobinuria

    • Important risk factors

    • –Recent surgery

      –Trauma

      –Cancer

      –Prolonged immobilization

      –Oral contraceptive use

    • Other risks

    • –Advanced age

      –Type A blood group

      –Obesity

      –Prior DVT

      –Multiparity

      –Inflammatory bowel disease

      –Systemic lupus erythematosus

    • Most common in calf ...

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