1
|
Negrão Pantaleão A, Goudot G, Becari L, Jeunon V, Andrade Bello G, Gallo de Moraes A. Pulmonary embolism following an undiagnosed Paget-Schroetter syndrome: a case report and review of the literature. PHYSICIAN SPORTSMED 2024; 52:414-420. [PMID: 37675985 DOI: 10.1080/00913847.2023.2256642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 09/08/2023]
Abstract
Paget-Schroetter Syndrome (PSS) is a rare condition characterized by spontaneous thrombosis of the axillary-subclavian vein that occurs predominantly in young athletes engaged in repetitive overhead upper extremity motion, for instance, weightlifting, swimming, baseball, and tennis. PSS is usually a consequence of chronic repetitive microtrauma to the vein intima due to compression of the axillary-subclavian vein by the thoracic outlet structures. This chronic injury can then be acutely exacerbated by vigorous exercise done over a brief period, accelerating thrombus formation. Lack of PSS awareness leads to underdiagnosis, misdiagnosis, or late diagnosis, which can pose life-threatening risks to patients, including pulmonary embolism (PE) and recurrent thrombosis. This case report of a 20-year-old male college athlete exposes a PE caused by PSS, potentially worsened by a delay in diagnosis. Early suspicion and proper management are crucial for optimizing long-term outcomes and facilitating limb rehabilitation. The recommended approach involves early catheter-directed thrombolysis followed by thoracic outlet decompression.
Collapse
Affiliation(s)
- Alexandre Negrão Pantaleão
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Guillaume Goudot
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Luca Becari
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vinicius Jeunon
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Alice Gallo de Moraes
- Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
2
|
Fisher AT, Lee JT. Diagnosis and management of thoracic outlet syndrome in athletes. Semin Vasc Surg 2024; 37:35-43. [PMID: 38704182 DOI: 10.1053/j.semvascsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 05/06/2024]
Abstract
The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
Collapse
Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA.
| |
Collapse
|
3
|
Pejkova S, Aleksovski D, Hadjitrifon S, Tusheva S, Georgieva G, Srbov B, Aszmann OC. Paget-Schroetter syndrome: the importance of early detection and effective surgical intervention. Arch Clin Cases 2023; 10:200-204. [PMID: 38155995 PMCID: PMC10754040 DOI: 10.22551/2023.41.1004.10275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
Paget-Schroetter syndrome (PSS) is relatively rare condition of thoracic outlet syndrome characterized by thrombosis or blood clot formation in the subclavian vein. Due to the non-specific symptoms and low incidence rate, PSS is frequently missed by medical professionals, and as such it often leads to wrong diagnosis and untreated patients. We present the case of a 30-year-old CrossFit trainer who developed a thrombosis of the subclavian vein. Initially, the patient consulted an internist after experiencing swelling in the right shoulder region and discoloration of the right upper extremity. Angiography revealed occlusion of the subclavian vein and anticoagulant therapy was prescribed. For more than a year, the patient's symptoms remained unchanged, and the subclavian vein occlusion persisted. Venography suspected effort thrombosis of the subclavian vein. The patient underwent surgery for decompression of the subclavian vein. After six months, results from post-operative computed tomography angiography showed that venous flow was fully restored and no pathology of the venous vessel wall could be demonstrated. This report aims to increase awareness of PSS among medical professionals, leading to earlier diagnosis and adequate clinical-surgical management.
Collapse
Affiliation(s)
- Sofija Pejkova
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Darko Aleksovski
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Sara Hadjitrifon
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Sofija Tusheva
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Gordana Georgieva
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Blagoja Srbov
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Oskar C. Aszmann
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Sen I, DeMartino R, Bjarnason H, Neisen M, Kalra M. Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome. Ann Vasc Surg 2023; 95:210-217. [PMID: 37285964 DOI: 10.1016/j.avsg.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/21/2023] [Accepted: 05/28/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol. METHODS Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into 2 groups-Group I: TL/PMT + TOD; Group II: medical management/anticoagulation + TOD. RESULTS PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL/PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n = 20) and 72% (n = 24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n = 6). Complete thrombus resolution was seen in 9% (n = 5). Residual chronic thrombus in 79% (n = 42) resulted in median SCV stenosis of 50% (range 10% to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2-8 months). Rethrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT/SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow-up of 14 months. Group II: 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow-up of 24 months. CONCLUSIONS For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.
Collapse
Affiliation(s)
- Indrani Sen
- Vascular and Endovascular Surgery, Mayo Clinic Health Systems, EauClaire, WI.
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Haraldur Bjarnason
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melissa Neisen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
5
|
Jenab Y, Tofighi S, Ayati A, Rezvanimehr A, Moosavi NS, Jalaie H, Barbati ME. Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study. BMC Cardiovasc Disord 2023; 23:351. [PMID: 37460994 DOI: 10.1186/s12872-023-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT. METHODS We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge. RESULTS Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients. CONCLUSIONS CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.
Collapse
Affiliation(s)
- Yaser Jenab
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Aryan Ayati
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Rezvanimehr
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Najme-Sadat Moosavi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Jalaie
- Department of Vascular and Endovascular Surgery, University Hospital Aachen, Aachen, Germany
| | | |
Collapse
|
6
|
Cavanna AC, Giovanis A, Daley A, Feminella R, Chipman R, Onyeukwu V. Thoracic outlet syndrome: a review for the primary care provider. J Osteopath Med 2022; 122:587-599. [PMID: 36018621 DOI: 10.1515/jom-2021-0276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/16/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS. OBJECTIVES This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options. METHODS The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS. RESULTS The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS. CONCLUSIONS The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.
Collapse
Affiliation(s)
- Angela C Cavanna
- Department of Clinical Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Athina Giovanis
- Department of Osteopathic Manipulative Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Alton Daley
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Feminella
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Chipman
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | | |
Collapse
|
7
|
A rare cause of upper extremity deep venous thrombosis: Paget Schroetter syndrome. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.919650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
8
|
Warrick A, Davis B. Neurogenic Thoracic Outlet Syndrome in Athletes - Nonsurgical Treatment Options. Curr Sports Med Rep 2021; 20:319-326. [PMID: 34099610 DOI: 10.1249/jsr.0000000000000854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Neurogenic thoracic outlet syndrome (NTOS) is an etiologically and clinically diverse disorder caused by compression of the brachial plexus traversing the thoracic outlet. Athletes who perform repetitive overhead activities are at risk of developing NTOS with sport-specific symptoms. This article reviews the controversial NTOS nomenclature, common sites of anatomic compression, and red flag symptoms that require immediate intervention. It also reviews the congenital, traumatic, and functional etiologies of NTOS, with a discussion of the differential diagnosis, diagnostic criteria, and workup for NTOS. Nonsurgical treatment is highlighted with an emphasis on thoracic outlet syndrome-specific physical therapy and updates on injection options and ultrasound guided hydrodissection. This article compares nonsurgical versus surgical functional outcome data with an emphasis on athletes with NTOS. Functional assessment tools and performance metrics for athletes are reviewed, as well as return to sport considerations.
Collapse
Affiliation(s)
- Alexandra Warrick
- Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, CA
| | | |
Collapse
|
9
|
Adekoya O. A Case of Upper Limb Venous Thrombosis in Paget-Schroetter Syndrome. Cureus 2021; 13:e13187. [PMID: 33717731 PMCID: PMC7941323 DOI: 10.7759/cureus.13187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Deep venous thrombosis (DVT) of the upper extremities is usually secondary to inflammatory processes, malignancy, immobility from trauma, and inherited or acquired thrombophilias. This is a case of a young man who presented to our facility complaining of upper extremity pain and swelling. Imaging results showed thrombosis in the deep venous system of the left upper extremity, consistent with Paget-Schroetter syndrome.
Collapse
|
10
|
Mattox R, Trager RJ, Kettner NW. Effort Thrombosis in 2 Athletes Suspected of Musculoskeletal Injury. J Chiropr Med 2020; 18:213-218. [PMID: 32874161 DOI: 10.1016/j.jcm.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/22/2018] [Accepted: 01/16/2019] [Indexed: 11/24/2022] Open
Abstract
Objective This case series describes the clinical presentation of effort thrombosis and the utility of sonography in its diagnosis. Clinical Features Two young male athletes presented to separate chiropractic clinics with suspected musculoskeletal shoulder injury. The first complained of dull shoulder pain after pitching in a baseball game and had no other signs or symptoms. The second presented after performing a weighted plank exercise and had prominent edema and discoloration of the affected extremity. Intervention and Outcome In the first patient, who had no physical signs to suggest thrombosis, a normal sonographic musculoskeletal shoulder exam prompted imaging in the abduction-external rotation position. This provided visualization of a thrombus in the axillosubclavian vein. Emergent referral followed, and treatment was initiated with thrombolysis and surgery, which resolved his condition. The second patient had physical signs consistent with effort thrombosis and was also referred to the emergency department, where sonography was performed and revealed thrombosis of the axillary and basilic veins. He responded to anticoagulants and thrombolysis and avoided surgery. Conclusion Effort thrombosis has a variable presentation that can mimic common musculoskeletal disorders and has a poorly defined diagnostic pathway. Acute shoulder pain in an athlete, especially with extremity edema after repetitive exertion, warrants urgent imaging such as sonography and emergent referral. Clinicians should understand the importance of a timely evaluation and diagnosis of effort thrombosis and that imaging may include sonography as a first-line imaging tool.
Collapse
Affiliation(s)
- Ross Mattox
- Department of Radiology, Logan University, Chesterfield, Missouri
| | | | - Norman W Kettner
- Department of Radiology, Logan University, Chesterfield, Missouri
| |
Collapse
|
11
|
Nakagami F, Yuasa K, Ohno M, Rakugi H. A Baseball Player with a Swollen Arm. Intern Med 2020; 59:1675-1676. [PMID: 32188807 PMCID: PMC7402966 DOI: 10.2169/internalmedicine.4139-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Futoshi Nakagami
- Department of General Internal Medicine, Osaka University Hospital, Japan
| | - Kunihiro Yuasa
- Department of Radiology, Suita Tokushukai Hospital, Japan
| | - Masato Ohno
- Department of Cardiac Surgery, Suita Tokushukai Hospital, Japan
| | - Hiromi Rakugi
- Department of Geriatric Medicine, Osaka University School of Medicine, Japan
| |
Collapse
|
12
|
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. Int J Surg Case Rep 2018; 49:81-86. [PMID: 29966955 PMCID: PMC6031594 DOI: 10.1016/j.ijscr.2018.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/15/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Paget-Schrotter Syndrome (PSS) also known as "effort thrombosis" is a form of primary thrombosis in the subclavian vein at the costoclavicular junction is usually seen in younger patients after repeated strenuous activity of the shoulders and arms. When occurring in younger patients, PSS presents itself with predisposing factors such as unilateral dull, aching pain in the shoulder or axilla and swelling of the arm and hand. CASE PRESENTATION We report a rare case of unusual left axillo-subclavian vein thrombosis following narrowing of thoracic outlet due to stress injury of rib fracture likely during gym activity in absence of other clear risk factors and a negative hypercoagulable workup in a 27-year-old man who was admitted as left deltoid rupture 5 days after his usual gym. Subsequently he was transferred under vascular surgery for thrombectomy. CONCLUSION In addition to the unusual location in the left upper extremity in our case, the absence of common etiologic factors makes our case of Paget-Schroetter Syndrome a very unique one. This case report aims to discuss the common causes of PSS in order to raise a high index of suspicion in certain groups of patients. This will allow early identification and avoidance of catastrophic outcomes such as pulmonary embolism and stroke.
Collapse
Affiliation(s)
- Vipul Garg
- Department of Orthopaedics, Sengkang General Hospital, Singapore.
| | - Glenys Poon
- National University of Singapore, Yong Loo Lin School of Medicine, Singapore
| | - Aprine Tan
- Department of Orthopaedics, Sengkang General Hospital, Singapore
| | - Kein Boon Poon
- Department of Orthopaedics, Sengkang General Hospital, Singapore.
| |
Collapse
|
13
|
Bishop M, Astolfi M, Padegimas E, DeLuca P, Hammoud S. Venous Thromboembolism Within Professional American Sport Leagues. Orthop J Sports Med 2017; 5:2325967117745530. [PMID: 29318176 PMCID: PMC5753956 DOI: 10.1177/2325967117745530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Numerous reports have described players in professional American sports leagues who have been sidelined with a deep vein thrombosis (DVT) or a pulmonary embolism (PE), but little is known about the clinical implications of these events in professional athletes. Purpose To conduct a retrospective review of injury reports from the National Hockey League (NHL), Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL) to take a closer look at the incidence of DVT/PE, current treatment approaches, and estimated time to return to play in professional athletes. Study Design Descriptive epidemiology study. Methods An online search of all team injury and media reports of DVT/PE in NHL, MLB, NBA, and NFL players available for public record was conducted by use of Google, PubMed, and SPORTDiscus. Searches were conducted using the professional team name combined with blood clot, pulmonary embolism, and deep vein thrombosis. Results A total of 55 venous thromboembolism (VTE) events were identified from 1999 through 2016 (NHL, n = 22; MLB, n = 16; NFL, n = 12; NBA, n = 5). Nineteen athletes were reported to have an upper extremity DVT, 15 had a lower extremity DVT, 15 had a PE, and 6 had DVT with PE. Six athletes sustained more than 1 VTE. The mean age at time of VTE was 29.3 years (range, 19-42 years). Mean (±SD) time lost from play was 6.7 ± 4.9 months (range, 3 days to career end). Seven athletes did not return to play. Players with upper extremity DVT had a faster return to play (mean ± SD, 4.3 ± 2.7 months) than those with lower extremity DVT (5.9 ± 3.8 months), PE (10.8 ± 6.8 months), or DVT with PE (8.2 ± 2.6 months) (F = 5.69, P = .002). No significant difference was found regarding time of return to play between sports. Conclusion VTE in professional athletes led to an average of 6.7 months lost from play. The majority of athletes were able to return to play after a period of anticoagulation or surgery. Those with an upper extremity DVT returned to play faster than those with other types of VTE. Further study is needed to look into modifiable risk factors for these events and to establish treatment and return-to-play guidelines to ensure the safety of these athletes.
Collapse
Affiliation(s)
- Meghan Bishop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Matthew Astolfi
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Eric Padegimas
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Peter DeLuca
- The Rothman Institute, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
14
|
Hangge P, Rotellini-Coltvet L, Deipolyi AR, Albadawi H, Oklu R. Paget-Schroetter syndrome: treatment of venous thrombosis and outcomes. Cardiovasc Diagn Ther 2017; 7:S285-S290. [PMID: 29399532 DOI: 10.21037/cdt.2017.08.15] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Thoracic outlet syndrome (TOS) is a rare clinical entity with many etiologies. Venous thoracic outlet syndrome (VTOS), also called Paget-Schroetter syndrome (PSS), is a primary "effort" thrombosis. Here we will focus on the pathophysiology, anatomy, clinical presentation, treatments, and outcomes of VTOS. Treatment involves anticoagulation, catheter-directed thrombolysis, and surgical decompression. Early diagnosis and treatment can improve symptoms and quality of life.
Collapse
Affiliation(s)
- Patrick Hangge
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Amy R Deipolyi
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
15
|
|
16
|
Abstract
Upper and lower extremity deep venous thrombosis (DVT) is defined as a blood clot within the deep veins of the affected extremities. These blood clots can either occur spontaneously or be associated with specific risk factors. Regardless of the cause, DVT is associated with significant morbidity and mortality and has the potential for lethal complications. The most notable complication is the potential for development of pulmonary embolism from a lower extremity DVT. As studies have reported, more than 90% of acute pulmonary emboli arise from the proximal veins. Venous thromboembolism is also associated with a significant economic burden on the health care system and the individual patient. In this article, we review DVT of the upper and lower extremity including risk factors, signs and symptoms, diagnosis, and management.
Collapse
|
17
|
Recurrent Upper Extremity Thrombosis Associated with Overactivity: A Case of Delayed Diagnosis of Paget-Schroetter Syndrome. Case Rep Vasc Med 2017; 2017:8764903. [PMID: 28775908 PMCID: PMC5523535 DOI: 10.1155/2017/8764903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022] Open
Abstract
Paget-Schroetter syndrome is thrombosis of the axillary-subclavian vein that is associated with strenuous and repetitive activity of the upper extremities. Overuse of the arm coupled with external compression results in microtrauma in the intima of the subclavian vein, resulting in the activation of the coagulation cascade. Diagnosis is usually made by Doppler ultrasound and the treatment involves thrombolysis, while routine surgical decompression of the thoracic outlet is controversial. In this report, we present a case of a patient who presented with a second episode of spontaneous right upper extremity deep venous thrombosis. The first episode was inadequately treated with oral anticoagulation alone. During the second episode, Paget-Schroetter syndrome was diagnosed, after careful review of his occupational history. He subsequently underwent angioplasty and decompression of thoracic outlet with no recurrence of thrombosis in a 12-month follow-up period.
Collapse
|
18
|
Iyer S, Angle JF, Uflacker A, Sharma AM. Venous Compression Syndromes: a Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:45. [PMID: 28470367 DOI: 10.1007/s11936-017-0541-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OPINION STATEMENT Venous compression syndromes present a diagnostic and therapeutic challenge as the clinical presentation can be vague, diagnostic criteria are often not present, and high quality standardization of when and how to treat is not available in part due to the limited number of cases reported and also due to the limited literature available. Significant venous compression should be considered when clinical symptoms correlate to location of compression and there is evidence of hemodynamic changes including venous hypertension, collateral/variceal formation, and/or thrombus formation. In general, treatment of venous compression should address the etiology of the compression as opposed to just treating symptoms associated with it such as significant varices or anticoagulation for thrombus to avoid recurrence of symptoms.
Collapse
Affiliation(s)
- Sunil Iyer
- Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John F Angle
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Andre Uflacker
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| |
Collapse
|
19
|
Mirza AK, Barrett IJ, Rathore A, Elhassan BT, Rose PS, Shives T, Bower TC. Soft Tissue Neoplasms Causing Apparent Venous Thoracic Outlet Syndrome. Ann Vasc Surg 2017; 42:306.e1-306.e4. [PMID: 28259825 DOI: 10.1016/j.avsg.2016.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/20/2016] [Indexed: 12/14/2022]
Abstract
Venous thoracic outlet syndrome (vTOS) usually results from compression of the subclavian vein classically as a result of narrowing of the costoclavicular space. We report 2 rare cases of soft tissue neoplasms resulting in apparent vTOS. The first case is a 46-year-old female with a 2-year history of intermittent unilateral shoulder pain, who was initially diagnosed with intervertebral disk herniation. Cervical fusion was performed; however, her symptoms progressed and she additionally developed paresthesias and venous congestion. Computed tomography (CT) angiogram demonstrated a 13-cm-encapsulated mass within the subscapularis muscle compressing the axillary vein. Radiological findings suggested lipoma. She subsequently underwent complete resection via a transaxillary approach with extension along the lateral border of the latissimus. Final pathology confirmed an intramuscular lipoma. The second case is a 21-year-old female who presented with acute onset of unilateral chest wall pain, palpable nodularity, and venous congestion. CT chest showed pulmonary embolism and an anterior chest wall mass. An initial attempt at resection was aborted due to proximity of the mass to the subclavian vein. The mass enlarged on serial imaging, measuring 3.8 cm in greatest dimension. Additionally, tumor thrombus was seen, and a subsequent ultrasound-guided biopsy was positive for high-grade synovial sarcoma. Positron emission tomography scan showed a pulmonary nodule that was resected thoracoscopically with pathology confirming metastatic synovial sarcoma. Subsequently, she underwent neoadjuvant chemoradiation followed by successful resection of the chest wall mass. An extended infraclavicular approach with a secondary transaxillary incision was utilized to achieve adequate exposure and margins. Final pathology was consistent with preoperative biopsy. Venous reconstruction was not needed. Although rare, an extrinsic mass as a cause of apparent TOS should be in the differential diagnosis. Surgical approach is based on tumor type, location, and proximity to the neurovascular bundle.
Collapse
Affiliation(s)
- Aleem K Mirza
- Division of Vascular Surgery, Mayo Clinic Rochester, Rochester, MN.
| | - Ian J Barrett
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Animesh Rathore
- Division of Vascular Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Bassem T Elhassan
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Thomas Shives
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Thomas C Bower
- Division of Vascular Surgery, Mayo Clinic Rochester, Rochester, MN
| |
Collapse
|
20
|
Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther 2017; 97:13-19. [PMID: 27587803 DOI: 10.2522/ptj.20150692] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 08/21/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Paget-Schroetter syndrome (PSS) is a rare condition of vein thrombosis that can be manifested in athletes and laborers who overuse their upper extremities. If diagnosed early, PSS can be managed and the symptoms can be fully reversed. Venous duplex ultrasound (US), the modality most commonly used to diagnose deep vein thrombosis (DVT), has high sensitivity and specificity for detecting DVT. This case report describes the differential diagnosis and management of PSS in a weight lifter. CASE DESCRIPTION The patient was a 44-year-old man who had left upper extremity (UE) swelling and discoloration after performing an incline chest press 2 months earlier. He was referred to a physical therapist for the treatment of venous thoracic outlet syndrome because US imaging results were negative for DVT. The patient's signs and symptoms did not improve after 4 physical therapist treatment sessions. OUTCOMES Repeat US revealed multiple thrombi in the patient's UE. He underwent immediate thrombolysis and subsequent first rib removal and scalenectomy. Five months after the surgical intervention, the patient had returned to work as a truck driver without limitation of UE use, although he had not yet returned to weight lifting. DISCUSSION Despite the facts that the patient was seen by several health care providers and that multiple US images were obtained, the patient's UE DVT was not detected. It is important for a clinician to consider venous pathology in the shoulder even if the results of diagnostic US imaging performed in the presence of UE swelling and pain have been negative. Timely diagnosis and management of PSS are necessary for optimal recovery.
Collapse
|
21
|
Upper Extremity Deep Vein Thromboses: The Bowler and the Barista. Case Rep Vasc Med 2016; 2016:9631432. [PMID: 27800207 PMCID: PMC5075304 DOI: 10.1155/2016/9631432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/02/2016] [Accepted: 09/18/2016] [Indexed: 11/17/2022] Open
Abstract
Effort thrombosis of the upper extremity refers to a deep venous thrombosis of the upper extremity resulting from repetitive activity of the upper limb. Most cases of effort thrombosis occur in young elite athletes with strenuous upper extremity activity. This article reports two cases who both developed upper extremity deep vein thromboses, the first being a 67-year-old bowler and the second a 25-year-old barista, and illustrates that effort thrombosis should be included in the differential diagnosis in any patient with symptoms concerning DVT associated with repetitive activity. A literature review explores the recommended therapies for upper extremity deep vein thromboses.
Collapse
|
22
|
|
23
|
Naeem M, Soares G, Ahn S, Murphy TP. Paget-Schroetter syndrome: A review and Algorithm (WASPS-IR). Phlebology 2015; 30:675-86. [DOI: 10.1177/0268355514568534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Venous compression syndromes are rare and occur due to the entrapment of vein(s) in confined anatomical spaces bounded by osseous and non-osseous structures. Here we present a review of Paget-Schroetter Syndrome, an important cause of upper extremity of deep vein thrombosis, its associated clinical and radiological findings as well as treatment options.
Collapse
Affiliation(s)
- M Naeem
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - G Soares
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - S Ahn
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - TP Murphy
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| |
Collapse
|
24
|
Keene DJ. Upper extremity deep vein thrombosis (Paget-Schroetter syndrome) after surfing: a case report. ACTA ACUST UNITED AC 2014; 20:358-60. [PMID: 25220111 DOI: 10.1016/j.math.2014.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/18/2014] [Accepted: 08/20/2014] [Indexed: 12/01/2022]
Abstract
This case report summarises the presentation of a 28-year-old female with signs and symptoms characteristic of thoracic outlet syndrome, but who was later found to have an effort-induced Upper Extremity Deep Vein Thrombosis (UEDVT), otherwise known as Paget-Schroetter syndrome. Effort-induced UEDVT is rare, but the similarity between the signs and symptoms of thoracic outlet syndrome and this type of thrombosis can result in patients with this condition presenting to musculoskeletal therapists. The key features of the case are described, followed by an overview of UEDVT and the importance of recognising this condition in musculoskeletal therapy practice. The role of therapists in referring for early medical diagnostics is key to ensuring management of the thrombosis is instigated early, therefore reducing the risk of life threatening consequences such as pulmonary embolism.
Collapse
Affiliation(s)
- David J Keene
- Kadoorie Centre for Critical Care Research & Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| |
Collapse
|
25
|
Walker KK. A content analysis of cognitive and affective uses of patient support groups for rare and uncommon vascular diseases: comparisons of may thurner, thoracic outlet, and superior mesenteric artery syndrome. HEALTH COMMUNICATION 2014; 30:859-871. [PMID: 24877701 DOI: 10.1080/10410236.2013.853225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Rare disease patients are the predominant group of patients who are now connecting online to patient support groups, yet research on their uses of support groups has received little attention. This is a content analysis of three vascular diseases of differing degrees of rarity. Wall posts from Facebook patient support groups for May Thurner syndrome, thoracic outlet syndrome, and superior mesenteric artery syndrome were analyzed over a period of two years. Using Uses and Gratifications as the theoretical framework, the study purpose was to assess how variations in health condition and rarity of condition affect online support group user needs. Results indicated common main cognitive and affective uses across conditions, indicating a consistent pattern of needs communicated by all patients. However, there were nuanced differences in subcategories of cognitive and affective uses between the most and least rare disorders, which inform areas for tailored support mechanisms. Additionally, these vascular patients used their respective support groups primarily for cognitive reasons, especially for the rarest conditions, which informs of basic medical informational needs these patients face related to tests, treatment, surgery, and diagnoses.
Collapse
|