Paget–Schroetter syndrome - thromboaspiration
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.