Paget-Schroetter syndrome: BMJ case report
A 21-year-old woman presented to the hospital for right lower neck pain. The patient reported that the pain started after she attempted to stretch backward. In addition, she complained of pain and swelling over her right upper arm which started a day after the neck pain started. Physical examination was positive for erythema, swelling and tenderness in the upper right arm and right subclavicular region.

Ultrasound venous of the right upper extremity revealed a large echogenic thrombus of the right subclavian vein. Given the above findings, further detailed history was obtained. The patient denied a family history of coagulation disorder. However, she admitted to being on oral contraceptive pills. Coagulation studies showed a normal protein S activity along with a negative factor V Leiden, anticardiolipin and prothrombin G20210A mutation. Antithrombin III level was slightly lower. The patient was subsequently placed on a heparin infusion and was scheduled to undergo thrombolysis.

Venography performed before procedure via the right basilic vein which revealed complete occlusion as the axillary vein and scant collateral vessels. The patient underwent intravenous catheter thrombolysis with 10 mg alteplase bolus continued with 1 mg/hour intravenous infusion for 24 hours without any complications. An interval venography which was performed after a day of the procedure demonstrated a reduction in the size of the subclavian thrombus but persistent large obstructing thrombus at the first rib.

There was a residual 80% obstruction that correlated with the triangle formed by the scalene anterior muscle posterior to the subclavian vein, the first rib beneath the vein and the clavicle above the vein. The obstruction appeared to be complex indicative of possible residual fibrotic material or thrombus. An additional 2 mg alteplase intracatheter bolus was given and intravenous infusion of 1 mg/hour was restarted for another 24 hours.

A 12 mm (length)×40 mm (diameter) balloon angioplasty with pressure of 10 atm was later performed. Interval venography showed persistent 80% obstruction in the subclavian vein with good flow into a central venous system with no progression compared with the previous image findings. No embolism following balloon angioplasty has been observed. The patient was discharged on rivaroxaban and was scheduled to undergo thoracic first rib resection in 3–4 weeks.

Learning points
• The presentation of severe pain in the extremities among patients with known anatomic abnormalities should raise a high index of suspicion for Paget-Schroetter syndrome and should be worked up appropriately.

• This upper extremity thrombotic event is usually preceded by strenuous exercise or repetitive movements of the upper extremity. However, there are a few case reports which mild activities could also trigger the event.

• Thrombolysis is reserved for patients presenting with moderate to severe symptoms. Even though surgical decompression is known to lower rates of recurrent thrombosis and reduce long-term morbidity, the recommendation is weak since it is based on observational studies.

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