Paget–Schroetter syndrome - thromboaspiration

Case contributed by Dr Francis Fortin

Presentation

Pain and swelling in right arm after increased physical activity. Accompanying dyspnea.

Patient Data

Age: 20 years
Gender: Male

Plain and annotated ultrasound image showing echogenic material (purple) representing thrombus in the right subclavian vein (blue).

Coronal MIP of CT pulmonary angiography shows multiple filling defects in bilateral segmental and subsegmental pulmonary arteries, in keeping with pulmonary emboli.

DSA (angiography)

Selected venography and angioplasty images showing right axillary and subclavian vein thrombus, which was subsequently aspirated and angioplastied. See next series of annotated images for more detail.

Annotated image

Image 1: There is a meniscus-shaped filling defect (purple) in the axillary vein, through which a Bentson guide (green arrow) has been passed. Prominent venous collaterals (blue) are seen upstream from the venous occlusion, indicative that there is hemodynamically significant obstruction. The ring (orange) of a Penumbra® 8 Fr catheter and an untied tourniquet (teal) are seen.

Image 2: Thromboaspiration is being done with a Penumbra® 8 Fr catheter (orange). Residual thrombus (purple) is seen in the right axillary vein.

Image 3: A bit of residual thrombus (purple) is seen in the axillary-subclavian vein. There is a fixed stenosis (blue) of the subclavian vein at its passage between the clavicle (organge) and the anterior surface of the 1st rib (hard to see on this image).

Image 4: Venous angioplasty is being done with a Mustang™ 10 mm x 4 cm balloon as the site of stenosis.

Image 5: Post-treatment injection shows almost complete recanalization of the axillary vein (blue). There is a bit of residual thrombosis and stenosis (orange) in the subclavian vein (purple). However, there are no more prominent venous collaterals, indicating that there is no longer hemodynamically significant obstruction to flow.

Small sample of some of the aspirated thrombus.

Case Discussion

Acute effort-induced axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) with pulmonary embolism (PE), treated initially with anticoagulation and endovenous thromboaspiration and angioplasty, with subsequent referral to vascular surgery.

Risk of PE with Paget-Schroetter syndrome is estimated at roughly 10%, less than when catheter-related. Patients are at risk for developing chronic venous hypertension of the affected upper limb.

Treatment includes systemic anticoagulation for at least 1 month, often 3 months, though this alone is usually deemed insufficient. Endovascular treatment options include (alone or in combination), with none proved superior: pharmacologic thrombolysis (rTPA or other agent), pharmacomechanical thrombolysis, and mechanical thrombectomy/thromboaspiration with devices that either use the venturi effect of simple aspiration. There is no proven benefit of angioplasty prior to definite surgical decompression, but it was performed in this case nonetheless. However, note that it is contraindicated to place a stent prior to surgical decompression.

Definite treatment usually involves surgical resection of the 1st rib, although this remains debated. There has been no randomized trial evaluating different treatment strategies for Paget-Schroetter syndrome at the time of publication of this case report.

This case is an adaptation of the Case Of The Week from Université de Montréal's collection available freely in French.

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Case information

rID: 78133
Published: 28th May 2020
Last edited: 29th May 2020
Inclusion in quiz mode: Included