Chapter 125

Paget-Schroetter syndrome is the sudden thrombosis of the subclavian vein in the setting of physical exertion of the arm. This syndrome is also known as effort thrombosis. It is the most extreme presentation of the venous form of thoracic outlet syndrome. It is a rare disease of active young people engaged in physical exertion of the arm (e.g., mechanics, rock climbers, swimmers, and weight lifters). Specifically, it is the forceful movement of pulling the extended arm from over the head down toward the torso that leads to the underlying basis of the disease: hypertrophy of the subclavius and anterior scalene muscles.

The subclavius is a small triangular muscle that originates from a groove on the undersurface of the clavicle and inserts by a short, thick tendon into the junction of the bony and cartilaginous first rib (Fig. 125-1). The subclavius muscle depresses the shoulder by drawing the clavicle downward and forward. The anterior scalene muscle arises from the transverse processes of the third to sixth cervical vertebrae and inserts onto the scalene tubercle on top of the first rib, separating the subclavian artery and vein. When an arm extended over the head is pulled down vigorously toward the torso, the anterior scalene fixes the first rib into position, anchoring it against the transverse processes of the neck. The subclavius muscle, in turn, anchors on the fixed first rib and pulls the shoulder down by displacing the clavicle.1

###### Figure 125-1.

A. The subclavian muscle originates from the undersurface of the clavicle and inserts into the junction of the bony and cartilaginous first rib. It lies in close proximity to the subclavian vein. B. Chronic forceful downward arm movements, such as, for example, when pitching a ball, creates the compressive pathology associated with Paget-Schroetter syndrome.

The sudden and forceful pulling down of the arm toward the torso is accomplished by the powerful contraction of the anterior scalene and subclavius muscles. The hypertrophied subclavius muscle in particular appears to be the cause of the pathologic injury. The sudden and powerful compression of the subclavian vein between these two muscles is sufficient to tear the intima of the vein, and thrombosis occurs. The clot then propagates distally toward the shoulder. Thrombolysis or anticoagulation alone may be insufficient to correct the clinical manifestations or to prevent recurrence. First rib resection with division of the two muscles prevents recurrence. The exposure given by an axillary approach to divide these muscles is inadequate and therefore not recommended. A subclavicular approach not only allows division of these muscles but also permits patch angioplasty of the vein.

Paget-Schroetter syndrome is a clinical diagnosis confirmed by duplex ultrasound or venogram. The ipsilateral arm frequently is swollen with distended veins up to the shoulder. Range of ...

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