Silent Killer - Page #4
 

Working Diagnosis:
Effort induced thrombosis (Paget-Schroetter Syndrome)

Treatment:
- Hospital admission 48 hours for thrombolysis
- Anticoagulation for 2 months
- Axillary surgery with first rib resection
- Followed by 2 months of anticoagulation

Outcome:
- 4 months off from start of treatment until full return to sport

Author's Comments:
The three most validated treatment options for Paget-Schroetter Syndrome are thrombolysis with surgical decompression followed with post-operative anticoagulation or no anticoagulation and thrombolysis with long term anticoagulation and surgery only if symptoms persist/rethrombosis. Treatment without thrombolysis and with just anticoagulation has shown more than 50% of patients develop chronic residual symptoms and should not be thought of as a standard of care option. Time from symptom onset to treatment is important as patients treated greater than 2-6 weeks after onset of symptoms had poorer symptom resolution and devloped chronic residual deficits usually unresponsive to surgery.(1)(2) In order to decide whether non-surgical or surgical options (+/-) anticoagulation are the treatment of choice for a patient, three factors must be consider : Symptoms (pain, function, swelling) recorded after thrombolysis treatment, age of the patient and timeframe for return to sport. Younger patients (

Editor's Comments:
Fairly common presentation that should be in the forefront of every sports medicine physician's mind. This case highlights this syndrome and all the various treatment options, combined in one case! Pictures are worth a thousand words here.

References:
Harold C Urschel, Jr, MD and Amit N. Patel. Surgery Remains the Most Effective Treatment for Paget-Schroetter Syndrome: 50 Years’ Experience. Ann Thorac Surg., 2008; 86; 254-60
J.Ernesto Molina, MD PhD, David W. Hunter, MD et al. Protocols for Paget-Schroetter Syndtome and Late Treatment of Chronic Subclavian Vein Obstruction. Ann Thorac Surg 2009; 87;416-22
Jason T. Lee, MD, John K Karwowski, MD. E. John Harris, MD, Jason Haukoos, MD and Cornelius Olcott IV, MD. Long –term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg., 2006; 1236-1243
Donayre CE, White GH, Mehringer SM, Wilson SE. Pathogenesis determines later morbidity of axillosubclavian vein thrombosis. AM J Surg 1986; 152: 179-84
Venkata M. Alla, MD, Nagendra Natarajan, MD et al. Paget-Schroetter Syndrom: Review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010; 358-362
LaBan, Myron M. MD, MMSc; Zierenberg, Adam MD et al. Clavicular- Induced Narrowing of the Thoracic Outlet during Shoulder abduction as Images by CT angiography and Enhanced by 3D reformation. Am J PM&R, 2011, 572-578
Dahlstrom, Kelly A. BS; Olinger, Anthony B. PhD. Descriptive Anatomy of the Interscalene Triangle and the Costoclavicular Space anf their relationship to Thoracic Outlet Syndrome. J M&P therapeutics, 2012,401

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