The Approach to a Patient With Paget

Spontaneous Upper Extremity Venous Thrombosis: The
Approach to a Patient With Paget-Schroetter Syndrome
Learning Objectives
•Understand the presentation of Paget-Schroetter
Syndrome (PSS)
•Review etiology of PSS
•Discuss the diagnostic evaluation of PSS
•Become familiar with the different treatment approaches
•Recognize that treatment requires a multi-disciplinary
team approach
James Ocampo, MD, and Andre Sofair, MD
Primary Care Internal Medicine Residency, New Haven, CT
Diagnostic Testing
Case Presentation
•38 yo right-handed male p/w 2 days of RUE pain and
•Plays in a bowling league and works in construction
•Noticed blue veins in his right chest and right shoulder
•Family Hx: Sister has APLS
•Labs: +ACL Ab, heterozygous mutation for MTHFR
Etiology of PSS
•AKA spontaneous axillosubclavian vein thrombosis
•Often occurs after strenuous use of the arm or shoulder
•Anatomic predisposition
•Hypercoagulable state
Case Continued
•16 days later, the patient has worsening right arm
•Ulltrasound revealed subclavian vein stenosis with
further extension of clot
•He was re-admitted to the hospital for administration
of TPA
•Flow was restored and symptoms improved
•Patient was discharged home
•Patient then underwent surgery for right scalene
muscle release
•He is currently being maintained on Warfarin and is
doing well
•The etiology of his PSS is likely multi-factorial:
hypercoagulable state and anatomic predisposition
•Patients present with dull pain in the shoulder and
axilla with swelling of the arm
•Dilation of collateral veins may be noted on
physical exam
•Ultrasound, venograms, and CT scans are useful
in the diagnosis of PSS
•Therapeutic options include anti-coagulant therapy,
fibrinolytic therapy, and surgical therapy
•Treatment decisions should be made by a multidisciplinary team of specialists