Working Diagnosis:
Venous thoracic outlet syndrome (VTOS) involving right brachial, axillary, and subclavian veins.
Paget-Schroetter syndrome aka "Effort Thrombosis" of the subclavian and axillary veins.
Case Photo #2

Treatment:
The patient underwent EKOS catheter directed thrombolysis followed by percutaneous mechanical thrombectomy of right brachial, axillary, and subclavian veins, and venoplasty of right axillary and subclavian veins. He was discharged from the hospital on Lovenox and vascular surgery recommended three months of anticoagulation prior to first rib resection, which was needed to more definitely decompress the subclavian vein. After the first month, Lovenox was changed to Eliquis 5 mg twice a day. The patient continued to require anti-hypertensive medication; hydralazine 25mg three times per day on hospital discharge, later transitioned to Lisinopril 40 mg daily.

Outcome:
Approximately 3 months later the patient complained of recurrent right arm pain and mild swelling.
He was found to have chronic right axillary and subacute subclavian deep vein thromboses.
Cleared by vascular to proceed with first rib resection, with instructions to continue anticoagulation (Eliquis) for 6 total months since initial deep vein thrombosis.
Cardiothoracic surgery performed first rib resection to more definitively decompress subclavian.
Following recovery from first rib resection, patient reported resolution of pain and swelling and was able to return to full training and competition without restrictions.
He did not require ongoing anticoagulation and is now normotensive without medication.

Author's Comments:
Thoracic outlet syndrome involves compression of neurovascular structures as they pass through one of three distinct regions of the neck and chest. These regions are the interscalene triangle, the costoclavicular space between the clavicle and first rib, and/or the retropectoralis minor space. The subclavian vein is typically affected in the costoclavicular space between the clavicle superiorly, the anterior scalene muscle posteriorly, and the first rib inferiorly. Paget-Schroetter syndrome is a specific type of venous thoracic outlet syndrome, known as effort thrombosis. The subclavian vein is subject to the nutcracker effect as it passes between the clavicle and first rib, and thrombosis is induced due to repetitive compression with arm movements. Features include pain, swelling, discoloration, and formation of collateral circulation. Management consists of anticoagulation, thrombolysis, and surgical decompression, typically via first rib resection, anterior scalenectomy, or resection of the costoclavicular ligament.
Case Photo #8
Case Photo #9

Editor's Comments:
There are three main types of thoracic outlet syndrome: neurogenic, venous, and arterial. Neurogenic thoracic outlet syndrome is the most common and presents with upper extremity pain, paresthesias, and weakness. Venous thoracic outlet syndrome is generally accompanied by arm swelling and cyanosis. The distinction between types of thoracic outlet syndrome is important because neurogenic thoracic outlet syndrome is treated with an initial trial of physical therapy and activity modifications. In contrast, venous thoracic outlet syndrome is treated more aggressively with anticoagulation, thrombolysis, and surgical decompression as noted above. Early identification and referral to vascular surgery is important in cases of venous thoracic outlet syndrome.

References:
Illig, Karl A. et al. A comprehensive review of Paget-Schroetter syndrome. Journal of Vascular Surgery, Volume 51, Issue 6, 1538 - 1547

Saleem T, Baril DT. Paget-Schroetter Syndrome. [Updated 2023 Apr 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482416/

Thiyagarajah K, Ellingwood L, Endres K, Hegazi A, Radford J, Iansavitchene A, Lazo-Langner A. Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis. Thromb Res. 2019 Feb;174:34-39. doi: 10.1016/j.thromres.2018.12.012. Epub 2018 Dec 8. PMID: 30553163.

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