Paget von schroetter syndrome
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The physical examination echoes the history, demonstrating a swollen, red-purple upper extremity, with prominent collaterals around the shoulder. Chronic microtrauma and subsequent fibrotic remodeling promote perivenous scarring and the development of extensive collateral venous networks.
Patients present with symptoms and signs of an upper limb deep vein thrombosis (i.e.
Clinical examination reveals unilateral upper extremity edema, typically with increased limb girth compared to the contralateral side. Various surrounding structures that lie in close proximity to subclavian vein, when it passes through the costoclavicular space, have been postulated to cause the compression.
The presence of thrombus can be confirmed on ultrasound or venography.
Paget Schroetter is deep vein thrombosis related to effort. Due to potential overlap with other hypercoagulable conditions, diagnostic workup should include evaluation for concurrent thrombophilic disorders. But options include:
- removing all or part of the rib
- removing part of the surrounding muscle
- removing part of the costoclavicular ligament
- breaking up of scar tissue around the vein
Another possible option is to insert a stent into the vein to keep it open, but surgery is a more permanent treatment for PSS.
People can recover after experiencing PSS.
A 2021 review of studies listed outcome rates of different treatments for PSS. Across 25 studies involving 1,511 people, thrombolysis resolved the clot in 78% of those who had this procedure.
Treatment involves blood-thinning medications and thrombolysis to get rid of the clot and decompression surgery to relieve pressure on the vein.
Emphasis is placed on early intervention and selecting appropriate candidates for surgical decompression. A complication of Paget Schroetter that has been described in early series of patients that were treated without surgery was 12% pulmonary emboli. Despite the relative rarity of Paget Schroetter syndrome, it has drawn quite a bit of attention in the literature and although most information regarding this disorder is limited to ‘expert opinions’ and ‘case-series’, there are many of those to read… We therefore attempted to summarize the clinically relevant, ‘down and dirty’ information that may serve to diagnose this disorder properly.
Mechanism of Paget Schroetter
The blood vessels leaving the chest into the arm traverse through the thoracic outlet.
When combined with CDT, mechanical thrombectomy may reduce thrombolytic dose and infusion time, thereby minimizing hemorrhagic risk.[13] Decompression of the thoracic outlet is the definitive management of PSS (see Image. A report of 50 year’s of a single center experience with over 600 cases of Paget Schroetter was published by Urschel and colleagues.
The affected limb may appear tense and cyanotic. Many individuals with PSS are athletes engaged in repetitive overhead arm movements, including baseball or softball pitchers, swimmers, rowers, and weightlifters.
Pathophysiology
PSS typically arises in the context of anatomical predispositions, particularly among individuals with a narrowed costoclavicular space or extrinsic compression of the subclavian vein.
It is a highly sensitive test in experienced hands. 2008;28(1):e28. weight-lifters, wrestlers, baseball pitchers or tennis players. Surveillance with duplex ultrasound may also serve to guide treatment duration, although this is more ‘common sense’ than ‘evidence based’. [PubMed: 27230515]
Garg V, Poon G, Tan A, Poon KB.
Paget-Schroetter syndrome as a result of 1st rib stress fracture due to gym activity presenting with Urschel's sign - A case report and review of literature.
Paget Schroetter Syndrome is a type of thoracic outlet syndrome.