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Taimur Saleem ; Donald T. Authors Taimur Saleem 1 ; Donald T. Baril 2. Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet.
It is the venous variant of thoracic outlet syndrome TOS , the syndrome of symptoms associated with compression of the subclavian vein, subclavian artery, or brachial plexus as they pass through the thoracic outlet.
This activity reviews the evaluation and management of Paget Schroetter syndrome and highlights the role of the interprofessional team in the care of patients with this condition. Objectives: Describe the pathophysiology of Paget Schroetter syndrome. Review the evaluation of a patient with Paget Schroetter syndrome. Summarize the treatment options for a patient with Paget Schroetter syndrome.
Explain modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by Paget Schroetter syndrome. Access free multiple choice questions on this topic. The description of this entity dates back to when Sir James Paget reported a case of spontaneous thrombosis of the subclavian vein in a patient.
In , von Schroetter hypothesized that the condition was a consequence of injury to the vein from repetitive musculoskeletal motion. The subclavian vein travels in the proximity of the clavicle, first rib, anterior scalene, and subclavius muscles. PSS is related to the compression and subsequent thrombosis of the subclavian vein due to these structures. PSS is more commonly seen in younger patients in their 20s and 30s with a male to female ratio of Often these patients will not have any other significant medical comorbidities.
The incidence ranges from 1 to 2 per , individuals per year in various studies. It is more commonly encountered on the right side. Often affected individuals with PSS will be athletes, specifically, those engaged in the repetitive over-the-head motion of their arms, including baseball or softball pitchers, swimmers, rowers, or weightlifters.
Repetitive strain from vigorous physical activity and compression of the subclavian vein from adjacent anatomic structures leads to venous injury and subsequent thrombosis. This impedes the venous return from the affected extremity leading to edema. Over time, the body forms collaterals to bypass the venous obstruction. In the chronic phase, the vein becomes fibrotic. Surrounding inflammatory changes from the thrombosis lead to scar tissue formation. Patients may present with upper extremity swelling and pain.
The presentation of these symptoms can be acute, subacute, or chronic. For the onset of symptoms in PSS, a history of an antecedent strenuous exercise can usually be elicited from the patients. On examination, the upper extremity will demonstrate edema with an enlarged girth of the extremity compared to the contralateral side. The upper extremity may be tense and cyanotic. A convenient non-invasive first test is ultrasonography of the upper extremities.
This will demonstrate thrombus in the deep venous system. Acute thrombus will be non-compressible on ultrasound. A vein with chronic thrombus will have an irregular and more collapsed appearance with the development of collaterals on ultrasound. Ultrasonography will not allow for complete demonstration of the central veins. Computed tomography CT venography and magnetic resonance MR venography can demonstrate thrombus in the venous system as well.
Contrast venography is a more invasive test that can demonstrate patency of the central venous system. Laboratory workup includes a thrombophilia panel protein C and S levels, antithrombin levels, prothrombin gene mutation analysis, factor V Leiden mutation testing, among others and D-dimer levels.
D-dimer levels will be elevated in a patient with deep venous thrombosis; however, this elevation can also be seen in other infectious, inflammatory, and physiologic conditions. If the patients have any symptoms concerning for a pulmonary embolism, a CT angiogram CTA thorax with pulmonary embolism protocol should be obtained. Alternatively, a ventilation-perfusion study can diagnose pulmonary embolism as well, but CTA thorax remains the study of choice. PSS is a deep venous thrombosis, and, as such, the first step in the management is to initiate anticoagulation therapy, typically, via an intravenous IV heparin drip.
Patients are given an initial bolus of intravenous IV heparin and then kept on a maintenance IV heparin drip. The dose of the bolus and maintenance heparin drip is weight-based.
The affected extremity should be elevated to mitigate edema. If the patient presents within 2 weeks of the onset of symptoms, it is reasonable to consider a venogram and catheter-directed thrombolysis to reduce the clot burden. Under fluoroscopic guidance, a lysis catheter is placed to drip a thrombolytic agent such as alteplase for 24 to 48 hours. Alternatively, a pharmacomechanical thrombectomy system can be used. When using alteplase, the fibrinogen levels should be monitored closely to direct the dosing and duration of the catheter-directed lysis.
When using pharmacomechanical thrombectomy, one should be mindful of the risk of acute kidney injury associated with hemolysis. If the presentation is more than 2 to 4 weeks from the onset of symptoms, heparinization alone may be initiated without thrombolytic therapy as the success of thrombolytic therapy is low beyond that window of time. Another option for treatment is mechanical catheter-directed thrombectomy. This must be done early in the course of the disease. Decompression of the thoracic outlet is the definitive management of PSS.
The surgical approach can either be transaxillary or supra, infra, or para-clavicular. The timing of decompression after thrombolytic therapy is widely debated. The role of long-term anticoagulation in these patients after adequate decompression remains unclear. Some clinicians perform a venogram, often with intravascular ultrasound, 2 weeks postoperatively and decide about the duration of anticoagulation at that time. In this setting, venoplasty can be used for any residual stenosis since decompression has been achieved surgically.
The use of stents is discouraged in this anatomic location due to the repetitive motion and risk of stent fracture and thrombosis. The duration of anticoagulation in patients with underlying hypercoagulability disorders after decompression also remains unclear.
In most patients, anticoagulation for 3 to 6 months following an episode of deep venous thrombosis such as PSS is reasonable. This can be achieved either via warfarin or direct oral anticoagulants DOAC.
In the case of recurrent thrombosis after decompression surgery, thrombolysis and venography are usually attempted again with the maintenance of long-term anticoagulation therapy afterward. In some patients with PSS, chronic total occlusion of the subclavian vein may persist despite adequate decompression maneuvers.
Depending on the severity of the symptoms, venous reconstruction should be considered. This can be achieved with a bypass or jugular vein turndown procedure with or without medial claviculectomy.
Upper extremity swelling may be present in patients with lymphatic disorders or systemic conditions such as end-stage renal disease and congestive heart failure. Upper extremity deep venous thrombosis can be seen with indwelling catheters as well.
Anticoagulation with decompression is less successful than thrombolysis and decompression but still yields better results than anticoagulation alone. Patients should be encouraged to adhere to all medication recommendations and have close follow up with all of their healthcare providers.
Activity and lifestyle modification may reduce the risk of recurrent thrombosis. Patients with hypercoagulable states should be made aware that they may need long-term anticoagulation. The diagnosis and management of PSS are best accomplished with an interprofessional team that consists of a primary care provider, sports medicine clinician, vascular surgeon, and radiologist.
Patients with venous obstruction do need treatment or the arm will remain swollen and painful. After anticoagulation, decompression of the thoracic outlet is often required. Most patients do have a good outcome with treatment but depending on the state of the subclavian vein, some degree of arm swelling may persist.
Today, for some cases of PSS, endovascular therapy is available. Patient with bilateral first rib resection. Contributed by StatPearls. The right subclavian artery and surrounding structures. Contributed by Gray’s Anatomy Public domain. This book is distributed under the terms of the Creative Commons Attribution 4.
Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Affiliations 1 St. Dominic Hospital. Continuing Education Activity Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet.
Introduction Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet. Etiology The subclavian vein travels in the proximity of the clavicle, first rib, anterior scalene, and subclavius muscles. Epidemiology PSS is more commonly seen in younger patients in their 20s and 30s with a male to female ratio of Pathophysiology Repetitive strain from vigorous physical activity and compression of the subclavian vein from adjacent anatomic structures leads to venous injury and subsequent thrombosis.
– Southern Medical Research Conference | Journal of Investigative Medicine
The new PMC design is here! Learn more about navigating our usa jobs government jobs login paget schroetter s syndrome meaning article layout. The PMC legacy view will also be available for a limited time. Federal government websites often end in. The site is secure. Paget-Schroetter syndrome, also known as venous thoracic outlet syndrome, посетить страницу primarily an effort-induced thrombosis of the subclavian and axillary veins.
Treatment modalities involve systemic anticoagulation, catheter-directed thrombolysis CDTand surgical decompression. Early endovascular intervention is noted to improve outcomes and result in symptomatic relief. Here we implore the usage of the novel mechanical aspiration thrombectomy device as an adjunct to CDT for the management страница peripheral venous thrombosis and highlight it as usa jobs government jobs login paget schroetter s syndrome meaning treatment option resulting in substantial radiological and symptomatic improvement.
Thoracic outlet syndrome TOS refers to a group of disorders that presents with features of neurovascular bundle compression as it traverses through the thoracic outlet.
According to the etiology, it is divided into neurogenic, venous, or arterial TOS. Venous TOS, also referred to by the eponym Paget-Schroetter syndrome, is primarily an effort-induced thrombosis of the subclavian and axillary veins. This syndrome results from excessive irritation schroteter impingement of the primary vein owing to schroether straining of the involved extremity. Populations with pagst already narrow costoclavicular space, through which the vein traverses, are highly predisposed.
It govvernment usually seen in the young athletic population with or without an underlying coagulopathy, who present with arm swelling, pain, and engorgement of veins in the chest wall. This case highlights the use of mechanical aspiration thrombectomy penumbra device as an adjunctive treatment to CDT for the management of venous TOS resulting in early symptomatic relief and substantial radiographic improvement.
A year-old female on oral contraceptives OCPs presented to the emergency department with three days of right upper extremity swelling and discomfort with movement. She leads eyndrome active lifestyle, including regular workout and practices axe throwing. Right upper extremity physical examination demonstrated visible swelling, tenderness to palpation over the biceps, and prominent venous vasculature.
Pertinent history was confirmed with the patient, including no prior history of thrombosis or contributing family history. Laboratory studies revealed hemoglobin of Beta-HCG testing was negative for pregnancy. Vascular ultrasound demonstrated deep venous thrombosis DVT within the right subclavian and axillary veins Figure 1. She underwent computed tomography angiography CTA of the chest, which was negative for pulmonary embolus PE ; however, redemonstrated acute DVT without extension into the superior vena cava SVC or the right jugular vein.
No regional masses were identified Figure 2. A diagnosis of acute DVT of the right axillary and subclavian veins attributed to effort-induced thrombosis was made. Oral anticoagulation with Rivaroxaban 15mg twice a day was prescribed, and OCPs were discontinued. Despite six days of treatment, she remained symptomatic with tenderness and swelling of the right upper extremity.
The patient was taken to the catheterization lab and underwent venography through the right forearm, demonstrating total occlusion of the subclavian vein Figure 3jobe was partially recanalized with balloon angioplasty; ссылка на продолжение, with significant clot burden was visualized in the axillary vein. The patient was noted to have severe venospasm unremitting to increasing sedation and nitroglycerin instillation.
Anti-factor-Xa levels were followed post heparin initiation, which usa jobs government jobs login paget schroetter s syndrome meaning within the therapeutic range 0.
After 12hrs of tPA infusion, repeat venography was performed. An attempt to reaccess the right basilic vein was unsuccessful due to severe venospasm. Therefore, the right common femoral vein access was obtained with an 18 G needle using the modified Seldinger technique, and an 8 Fr Cordis 11 cm sheaths Cardinal Health, USA was placed. Venography demonstrated significant recanalization of the axillary and subclavian veins but with persistent moderate thrombus burden Figure 4 at the site of compression.
Subsequently, balloon angioplasty using 6. There were no immediate complications. The patient reported marked improvement in symptoms the following day, and she was discharged home on Rivaroxaban for three months.
She was referred to cardiothoracic surgery to explore potential surgical therapies for PSS. The patient was educated regarding pregnancy planning and post-thrombotic syndrome. She ultimately underwent surgery for thoracic outlet syndrome, including first rib resection and C7 scalenectomy, and continued to be symptom-free on follow-up visits. A myriad of approaches have been described in the literature for treatment of acute DVT. However, there is no clear consensus on the best initial approach; hence treatment should be tailored to the underlying causative factors and reviewed on a case-to-case basis, based on the clinical presentation, severity and resource availability.
The cornerstone of the treatment is anticoagulation which can vary from utilizing subcutaneous low molecular weight heparin LMWH to intravenous unfractionated heparin with monitoring to the newer target-specific oral anticoagulants.
Anticoagulation by itself prevents thrombus propagation and its nobs but is limited by the fact that it does not lyse the existent thrombus and does not prevent post-thrombotic complications. The amelioration of symptoms following anticoagulation is related more to the development of collateral logib rather than the resolution of the thrombus itself [ 2 ].
The second option to the treatment strategy includes thrombolysis for better resolution of the clot burden leading to symptomatic benefit. Catheter directed thrombolysis CDT is preferred over systemic thrombolysis to avoid joobs exposure to tissue plasminogen activator tPA and potentially limit the adverse bleeding risks.
It is noteworthy that CDT is indicated for patients with an acute clot of less than 14 days duration and without any contraindications to thrombolysis. Здесь clot of more здесь two weeks in duration is associated with limited success attributed to thrombus organization [ 3 ].
Hence, if the patient is symptomatic, presents in a timely fashion, or has a massive clot burden, the use of thrombolytic therapy is advocated. However, the use of CDT is not entirely devoid of risks. When compared with anticoagulation alone, the syndgome of CDT results in significant complications, including risks of major bleeding and PE [ 4 ].
The higher risk of bleeding is explained by the fact that using CDT exposes patients to a longer duration and higher cumulative dosage of tPA. Moreover, administration of CDT therapy requires monitoring in the intensive care unit for the duration of treatment leading to higher procedural costs and healthcare resource utilization.
To mitigate time and costs, there have been limited studies and case reports utilizing pharmacomechanical thrombectomy PMT as a therapeutic approach for the removal of thrombus. Usage of PMT results in improved restoration of patency and low severity of post e sequelae when compared to CDT therapy alone [ 5 ]. When used in combination with CDT, it brings down the exposure time to tPA, thereby reducing the bleeding complications [ 7 ].
It also reduces uaa length of pzget required in intensive care settings and the overall hospital cost. However, it is worthwhile to remember that in cases of Paget-Schroetter syndrome, the usage of thrombolysis and anticoagulation results in symptomatic success, but there is usually an underlying factor resulting in the extrinsic sdhroetter that needs to be addressed using surgical approach to prevent recurrent episodes.
Paget-Schroetter syndrome is an продолжение здесь induced thrombosis of the subclavian and axillary veins. The fundamental approach to treatment is anticoagulation, with more advanced strategies, including catheter directed usa jobs government jobs login paget schroetter s syndrome meaning and pharmacomechanical thrombectomy. Mechanical thrombectomy Penumbra device can be used as primary or adjunctive therapy along with catheter directed thrombolysis for treatment.
The Penumbra device is a novel system that generates a near usa jobs government jobs login paget schroetter s syndrome meaning enabling removal of thrombus from vessels of the peripheral venous and arterial system resulting in significant improvement within the patency of the vascular lumen and restoration of normal flow. The combination results in better safety profile for the patient, early symptomatic relief and lesser stay in intensive care settings.
However, identifying the underlying cause of Paget-Schroetter usa jobs government jobs login paget schroetter s syndrome meaning is paramount to preventing recurrent episodes. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein.
Usa jobs government jobs login paget schroetter s syndrome meaning content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute jons the advice of a qualified health care professional. Посмотреть больше not disregard or avoid professional medical advice due to content published within Cureus. The ссылка на подробности have declared that no competing interests exist.
Consent was obtained or waived by all participants in this study. Published online Apr Author information Article notes Copyright and License интересно!
what federal jobs are available Вам Disclaimer. Corresponding author. Goveenment Singh moc. Accepted Apr psget This is an open access article distributed under the terms of the Creative Commons Продолжить чтение License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Paget-Schroetter syndrome, читать known as venous thoracic outlet syndrome, is primarily an effort-induced thrombosis of the subclavian and axillary veins. Keywords: pvd: peripheral vascular disease, paget-schroetter syndrome, deep vein thrombosis dvtmechanical thrombectomy mtcatheter-directed thrombolysis.
Introduction Thoracic outlet syndrome TOS refers to a group of disorders that presents with features of neurovascular bundle compression as it traverses through the thoracic outlet. Case presentation A year-old female on oral contraceptives OCPs presented to the emergency department with three days of right upper extremity swelling and discomfort with movement. Figure 1. Open in a separate window. Duplex ultrasound reveals non-compressibility and lack of flow in the right axillary vein consistent with occlusive deep vein thrombosis.
Figure 2. Delayed phase on CT angiography demonstrating a large filling defect in the mid and distal right subclavian vein. The right internal jugular and superior vena cava were patents. Figure 3. Axillary venography demonstrating complete occlusion of the right subclavian vein.
Figure 4. Post catheter directed thrombolysis showing recanalization of the subclavian and axillary veins but with residual thrombus in the mid subclavian vein at the site of compression. Figure 5. Digital subtraction venography post mechanical thrombectomy with significant improvement in the thrombus burden. Discussion A myriad of approaches have been described in the literature for treatment of usa jobs government jobs login paget schroetter s syndrome meaning DVT.
Conclusions Paget-Schroetter syndrome is an effort induced usa jobs government jobs login paget schroetter s syndrome meaning of the subclavian and axillary veins.
Human Ethics Consent was obtained or waived by all participants in this study. References 1. National Organization for Rare Disorders: Thoracic outlet syndrome.
Paget-Von Schrötter Syndrome – definition of Paget-Von Schrötter Syndrome by The Free Dictionary.You are being redirected
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