50 Y/o Female Kayaker With Arm Pain And Swelling - Page #4

Working Diagnosis:
Effort Thrombosis or Paget-Schroetter syndrome or Thoracic Inlet Syndrome

The patient was advised against participating in her rafting trip. TPA infusion was discussed with vascular surgery and interventional radiology, but the patient declined these interventions, electing instead for lifestyle modification and anticoagulation with warfarin. Enoxaparin 1 mg/kg subcutaneous twice a day was initiated until warfarin was in therapeutic range. Warfarin was continued for 6 months.

Successful treatment of effort thrombosis with minimal residual venous insufficiency without functional limitation or deficit.

Author's Comments:
She returned to her normal level of activity after warfarin treatment concluded. Hypercoaguable work up was negative.

Editor's Comments:
Patients with effort thrombosis often report a discrete precipitating event, usually sports-related arm exertion or increase in activities such as this patient. Swelling and arm discomfort are the most frequent presenting problems with other symptoms including heaviness, redness of arm, cyanosis and dilated, visible veins across the shoulder and upper arm (Urschel’s sign). These symptoms and signs have poor specificity, and less than 50% of those with suggestive symptoms actually have deep venous thrombosis. Doppler ultrasonography is the preferred initial test, while contrast venography remains the gold standard for diagnosis. Contemporary management of effort thrombosis varies widely, and there is no broad consensus as to what constitutes the best approach. Effort thrombosis is often managed using a multimodal approach consisting of catheter-directed thrombolysis, early thoracic outlet decompression in appropriate patients and physical and occupational therapy.

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.

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