Working Diagnosis:
Primary upper extremity deep venous thrombosis secondary to an effort thrombosis (Paget-Schroetter syndrome)

Treatment:
The patient underwent right first rib resection with percutaneous thrombectomy of the subclavian and axillary veins after a trial of Eliquis (apixaban) proved insufficient. His course was complicated by recurrent deep venous thromboses and a postoperative hematoma which caused severe pre-renal acute kidney injury, requiring ten days of dialysis in a two week hospital stay. After three thrombectomies, his vessels remained patent.

Outcome:
Outcome: After three thrombectomies with subclavian recanalization, venoplasty, right 1st rib resection, and completion of six months of anticoagulation, his vessels continued to remain patent.
Return to Play: Although the affected vessel remains patent, the patient continued to experience persistent symptoms consistent with neurogenic thoracic outlet syndrome. Although he was cleared to return to play by vascular surgery and nephrology, a multidisciplinary assessment was required. After comprehensive evaluation, the sports medicine team concluded that, given the overall clinical picture, including the risk of recurrent injury and the potential for recurrence of his complex VTE, medical disqualification was the most appropriate course of action.

Author's Comments:
This case highlights Paget-Schroetter syndrome in a high-level athlete, a rare form of venous thoracic outlet syndrome occurring in 1-2 per 100,000 cases annually. It results from effort-induced thrombosis of the subclavian vein. Most commonly, repetitive upper limb exertion superimposed on anatomical predisposition causes subclavian vein compression, endothelial injury, inflammation, and ultimately thrombosis. Early recognition and management, including anticoagulation and, when indicated, surgical decompression are critical to restore venous patency, prevent recurrence, and guide safe return to play in competitive sports.

Editor's Comments:
This case illustrates the importance of including Paget-Schroetter syndrome on the differential with this presentation and the benefits of work up with vascular studies including doppler and CT angiogram despite negative laboratory studies. Due to the severity of the condition and risk of recurrence, retirement from play may be recommended. Shared decision-making should be be emphasized while presenting the best evidence with the patient.

References:
Bose S, Desikan S. Overview of peripheral vascular problems in athletes. In: Post TW, ed.UpToDate. Wolters Kluwer; 2026. Updated October 23, 2025. Accessed March 11, 2026.https://www.uptodate.com
Bushnell BD, Anz AW, Dugger K, Sakryd GA, Noonan TJ. Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher. Sports Health. 2009;1(6):493-499. doi:10.1177/1941738109347980
Darling RC III, Ozaki CK, eds. Vascular surgery: hybrid, venous, dialysis access, thoracic outlet, and lower extremity procedures. Part 4: Thoracic outlet procedures. Wolters Kluwer; [2016].
Goshima K. Primary spontaneous upper extremity deep vein thrombosis. In: Eidt JF, Mills JL Sr, eds. UpToDate. Post TW, ed. Waltham, MA: UpToDate Inc. Accessed June 20, 2025.
Goshima K, Mills JL Sr, Eidt JF, Shefner JM. Overview of thoracic outlet syndromes. In: Post TW, ed. UpToDate. Wolters Kluwer; 2026. Accessed June 20, 2025.
Koethe Y, Bochnakova T, Kaufman CS. Upper Extremity Deep Venous Thrombosis: Etiologies, Diagnosis, and Updates in Therapeutic Strategies. Semin Intervent Radiol. 2022;39(5):475-482. Published 2022 Dec 20. doi:10.1055/s-0042-1757937
Trenor CC 3rd, Fisher JG, Khan FA, et al. Paget-Schroetter syndrome in 21 children: outcomes after multidisciplinary care. J Pediatr. 2015;166(6):1493-7.e1. doi:10.1016/j.jpeds.2015.03.030

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