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When using alteplase, the fibrinogen levels should be monitored closely to direct the dosing and duration of the catheter-directed lysis.
When using pharmacomechanical thrombectomy, one should be mindful of the risk of acute kidney injury associated with hemolysis. If the presentation is more than 2 to 4 weeks from the onset of symptoms, heparinization alone may be initiated without thrombolytic therapy as the success of thrombolytic therapy is low beyond that window of time.
Another option for treatment is mechanical catheter-directed thrombectomy. This must be done early in the course of the disease. Decompression of the thoracic outlet is the definitive management of PSS. The surgical approach can either be transaxillary or supra, infra, or para-clavicular.
The timing of decompression after thrombolytic therapy is widely debated. The role of long-term anticoagulation in these patients after adequate decompression remains unclear. Some clinicians perform a venogram, often with intravascular ultrasound, 2 weeks postoperatively and decide about the duration of anticoagulation at that time.
In this setting, venoplasty can be used for any residual stenosis since decompression has been achieved surgically. The use of stents is discouraged in this anatomic location due to the repetitive motion and risk of stent fracture and thrombosis.
The duration of anticoagulation in patients with underlying hypercoagulability disorders after decompression also remains unclear. In most patients, anticoagulation for 3 to 6 months following an episode of deep venous thrombosis such as PSS is reasonable.
This can be achieved either via warfarin or direct oral anticoagulants DOAC. In the case of recurrent thrombosis after decompression surgery, thrombolysis and venography are usually attempted again with the maintenance of long-term anticoagulation therapy afterward. In some patients with PSS, chronic total occlusion of the subclavian vein may persist despite adequate decompression maneuvers.
Depending on the severity of the symptoms, venous reconstruction should be considered. This can be achieved with a bypass or jugular vein turndown procedure with or without medial claviculectomy. Upper extremity swelling may be present in patients with lymphatic disorders or systemic conditions such as end-stage renal disease and congestive heart failure.
Upper extremity deep venous thrombosis can be seen with indwelling catheters as well. Anticoagulation with decompression is less successful than thrombolysis and decompression but still yields better results than anticoagulation alone.
Patients should be encouraged to adhere to all medication recommendations and have close follow up with all of their healthcare providers. Activity and lifestyle modification may reduce the risk of recurrent thrombosis. Patients with hypercoagulable states should be made aware that they may need long-term anticoagulation. The diagnosis and management of PSS are best accomplished with an interprofessional team that consists of a primary care provider, sports medicine clinician, vascular surgeon, and radiologist.
Patients with venous obstruction do need treatment or the arm will remain swollen and painful. After anticoagulation, decompression of the thoracic outlet is often required. Most patients do have a good outcome with treatment but depending on the state of the subclavian vein, some degree of arm swelling may persist.
Today, for some cases of PSS, endovascular therapy is available. Patient with bilateral first rib resection. Contributed by StatPearls. The right subclavian artery and surrounding structures. Contributed by Gray’s Anatomy Public domain. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Affiliations 1 St.
Dominic Hospital. Continuing Education Activity Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet. Introduction Paget Schroetter syndrome PSS is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet.
Etiology The subclavian vein travels in the proximity of the clavicle, first rib, anterior scalene, and subclavius muscles. Epidemiology PSS is more commonly seen in younger patients in their 20s and 30s with a male to female ratio of Pathophysiology Repetitive strain from vigorous physical activity and compression of the subclavian vein from adjacent anatomic structures leads to venous injury and subsequent thrombosis.
History and Physical Patients may present with upper extremity swelling and pain. Evaluation A convenient non-invasive first test is ultrasonography of the upper extremities. Differential Diagnosis Upper extremity swelling may be present in patients with lymphatic disorders or systemic conditions such as end-stage renal disease and congestive heart failure.
Complications Pulmonary embolism. Deterrence and Patient Education Patients should be encouraged to adhere to all medication recommendations and have close follow up with all of their healthcare providers. Enhancing Healthcare Team Outcomes The diagnosis and management of PSS are best accomplished with an interprofessional team that consists of a primary care provider, sports medicine clinician, vascular surgeon, and radiologist. Review Questions Access free multiple choice questions on this topic.
Comment on this article. Figure Patient with bilateral first rib resection. Figure cervical rib on chest x-ray. Image courtesy S Bhimji MD.
Figure The right subclavian artery and surrounding structures. Figure Cervical rib. References 1. Turk Kardiyol Dern Ars. Kardiol Pol. On the centenary of the death of Sir James Paget and on the 50th anniversary of the naming of the syndrome]. Dtsch Med Wochenschr. Variability in the management of line-related upper extremity deep vein thrombosis. Effort Thrombosis Provoked by Saxophone Performance.
J Emerg Med. Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis. Thromb Res. J Pediatr. J Tehran Heart Cent. American Society of Hematology guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism.
Blood Adv. Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients. Paget-Schroetter syndrome. BMJ Case Rep. Uses Schedule A , a non-competitive hiring process. It’s faster and easier than the competitive process. Provides reasonable accommodations to qualified employees. You can also apply for jobs through the competitive hiring process. It covers Schedule A and other factors in applying for a job.
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