Over Rehearsed

Abstract

21-year-old black man presented with acute onset of rightarm and shoulder swelling with associated pain one dayafter performing 100 push-ups. He had been previously healthyand active with no significant past medical history. In particular,he had no antecedent history of shoulder trauma or deep venousthrombosis. He was right-handed and played the cello up to 6hours a day. Physical examination on admission was notable foredema involving the right upper arm, shoulder, and infraclavic-ular region. Abduction of the right arm was restricted because ofpain. Jugular venous pressure was not elevated. No dilatedsuperficial or collateral veins were seen on the anterior chestwall. No pulse or neurological deficits were noted in the rightarm at baseline or with attempts at Adson maneuver (neckextension, head away from affected side, and a deep breath).Duplex ultrasound of the right upper extremity revealed acutenonocclusive thrombus in a dilated axillary vein (Figure 1). Thevein walls were partially compressed with external transducerpressure, and spontaneous Doppler flow was minimal withdelayed augmentation on forearm compression. No cervical ribwas seen on chest x-ray, and computerized tomography angiog-raphy of the chest showed no pulmonary emboli. Prothromboticscreen was negative for activated protein-C resistance, pro-thrombingenemutationG20210A,proteinSandCdeficiencies,antithrombin III deficiency, lupus anticoagulant, anticardiolipinantibodies, and hyperhomocysteinemia.The patient was anticoagulated with intravenous unfrac-tionated heparin on admission. His symptoms and edemagradually lessened over the ensuing 4 days. Contrast venog-raphy was performed with the intent to perform catheter-directed thrombolysis, mechanical thrombectomy, or both.Venography revealed patent right axillary and subclavianveins with no evidence of thrombus (Figure 2). Maturecollateral venous communications, however, were foundbetween the axillary and subclavian veins. An Adson maneu-ver performed during venography demonstrated dynamicobstruction of the axillary vein lateral to the thoracic inletwhile flow was still visualized through the venous collateralnetwork (Figure 3). The patient was discharged on oralanticoagulation therapy. Orthopedic opinion is pending forpossible musculoskeletal pathogenesis.Paget-Schroetter syndrome (effort-induced axillary-subclavian vein thrombosis) typically presents after vigorousactivity involving arm abduction, cervical extension, andshoulder depression, especially in the presence of a mechan-ical abnormality at the thoracic inlet where the vein iscompressed between a hypertrophied anterior scalene muscleor subclavius tendon and the first rib. It is postulated thatmicrotrauma to the venous vessel wall activates the coagula-