PAGET-SCHROETTER SYNDROME: "EFFORT THROMBOSIS” DISCOVERED AFTER AIR TRAVEL

Abstract

SESSION TITLE: Thrombosis Jamboree: Rare and Unique CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Paget-Schroetter syndrome (PSS), also known as "effort thrombosis” affects 1 to 2 per 100,000 individuals yearly (1). PSS is a type of venous thoracic outlet syndrome (VTOS) that causes spontaneous thrombosis of the subclavian vein at the level of the costoclavicular junction. Etiology involves an injury to the vein over time, which leads to spontaneous manifestation of edema and pain. Prompt recognition of PSS is crucial in the prevention of further complications.CASE PRESENTATION: A 47-year-old male with no known medical history presents with severe left arm pain with edema. The patient presented less than 48 hours from an 11-hour flight when he started developing symptoms upon arrival. Physical exam revealed left upper extremity swelling, which was double the size of the right. The remainder of exam and laboratory workup was unremarkable. Duplex ultrasound revealed deep vein thrombosis (DVT) within the brachial vein, extending to the subclavian vein. The patient was started on a heparin drip and underwent a venogram with mechanical thrombectomy and thrombolysis. The patient tolerated the procedure well and was subsequently diagnosed with PSS. The patient was discharged with an oral anticoagulant and advised to not bear weight or extend the arm above shoulder level until seen by a VTOS specialist.DISCUSSION: PSS can present with intermittent symptoms of pain or edema of the affected extremity. However, true effort thrombosis often presents acutely with severe symptoms (1). Diagnosis involves duplex ultrasound, careful history, and physical examination. Venography remains the gold standard, which reveals the occlusion close to the costoclavicular junction, along with the presence of venous collaterals (3). Definitive therapy remains controversial, however, studies support the mechanism and success behind the removal of the anterior first rib after thrombectomy (2,3).The role air travel plays with the presentation of our patient remains unclear. Etiology involves the traumatic forces on the subclavian vein that subsequently leads to inflammation and eventual connective tissue fibrosis of the surrounding vessel (1). Despite successful thrombectomy, patients benefit from a multimodal approach, including surgical intervention to reduce long-term complications. Patients with PSS carry a greater risk of chronic pain and swelling compared to an upper extremity DVT alone. Additional measures include thrombolytic therapy and anticoagulation, however, there is no definitive consensus on management.CONCLUSIONS: PSS commonly affects males ages 20-30s, often after an inciting event such as the repetitive use of the affected limb. Although studies on the exact timing of the development of symptoms vary in theories, prompt recognition of PSS is crucial. Management post-thrombectomy remains controversial in terms of necessitating surgical intervention.Reference #1: Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010 Jun;51(6):1538-47. doi: 10.1016/j.jvs.2009.12.022. Epub 2010 Mar 20. PMID: 20304578.Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362.Reference #3: Thompson RW. Comprehensive management of subclavian vein effort thrombosis. Semin Intervent Radiol. 2012;29(1):44-51. doi:10.1055/s-0032-1302451DISCLOSURES: No relevant relationships by Livasky Concepcion PerezNo relevant relationships by Nicolas HanaberghNo relevant relationships by Antonia HarrisNo relevant relationships by Czarina Teano SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Paget-Schroetter syndrome (PSS), also known as "effort thrombosis” affects 1 to 2 per 100,000 individuals yearly (1). PSS is a type of venous thoracic outlet syndrome (VTOS) that causes spontaneous thrombosis of the subclavian vein at the level of the costoclavicular junction. Etiology involves an injury to the vein over time, which leads to spontaneous manifestation of edema and pain. Prompt recognition of PSS is crucial in the prevention of further complications. CASE PRESENTATION: A 47-year-old male with no known medical history presents with severe left arm pain with edema. The patient presented less than 48 hours from an 11-hour flight when he started developing symptoms upon arrival. Physical exam revealed left upper extremity swelling, which was double the size of the right. The remainder of exam and laboratory workup was unremarkable. Duplex ultrasound revealed deep vein thrombosis (DVT) within the brachial vein, extending to the subclavian vein. The patient was started on a heparin drip and underwent a venogram with mechanical thrombectomy and thrombolysis. The patient tolerated the procedure well and was subsequently diagnosed with PSS. The patient was discharged with an oral anticoagulant and advised to not bear weight or extend the arm above shoulder level until seen by a VTOS specialist. DISCUSSION: PSS can present with intermittent symptoms of pain or edema of the affected extremity. However, true effort thrombosis often presents acutely with severe symptoms (1). Diagnosis involves duplex ultrasound, careful history, and physical examination. Venography remains the gold standard, which reveals the occlusion close to the costoclavicular junction, along with the presence of venous collaterals (3). Definitive therapy remains controversial, however, studies support the mechanism and success behind the removal of the anterior first rib after thrombectomy (2,3). The role air travel plays with the presentation of our patient remains unclear. Etiology involves the traumatic forces on the subclavian vein that subsequently leads to inflammation and eventual connective tissue fibrosis of the surrounding vessel (1). Despite successful thrombectomy, patients benefit from a multimodal approach, including surgical intervention to reduce long-term complications. Patients with PSS carry a greater risk of chronic pain and swelling compared to an upper extremity DVT alone. Additional measures include thrombolytic therapy and anticoagulation, however, there is no definitive consensus on management. CONCLUSIONS: PSS commonly affects males ages 20-30s, often after an inciting event such as the repetitive use of the affected limb. Although studies on the exact timing of the development of symptoms vary in theories, prompt recognition of PSS is crucial. Management post-thrombectomy remains controversial in terms of necessitating surgical intervention. Reference #1: Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010 Jun;51(6):1538-47. doi: 10.1016/j.jvs.2009.12.022. Epub 2010 Mar 20. PMID: 20304578. Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. Reference #3: Thompson RW. Comprehensive management of subclavian vein effort thrombosis. Semin Intervent Radiol. 2012;29(1):44-51. doi:10.1055/s-0032-1302451 DISCLOSURES: No relevant relationships by Livasky Concepcion Perez No relevant relationships by Nicolas Hanabergh No relevant relationships by Antonia Harris No relevant relationships by Czarina Teano