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| Year : 1983 | Volume
: 29
| Issue : 3 | Page : 175-6 |
Paget-Schroetter syndrome.
Sanghavi ST, Vardhachary KS, Hoda AA
How to cite this article:
Sanghavi S T, Vardhachary K S, Hoda A A. Paget-Schroetter syndrome. J Postgrad Med 1983;29:175 |
Occurence of deep vein thrombosis is quite common and has become an important problem during the post-operative and post-partum periods and also in diseases requiring prolonged confinement to bed, e.g. myocardial infarction. Oral contraceptives which are now extensively being used have added considerably to this problem in the recent past. The most common sites for these venous thrombosis are leg and pelvic veins. Primary subclavian vein thrombosis is relatively an uncommon condition. It was first described by Paget[3] in 1875, and Schroetter[11] in 1884 independently. Huges,[4] while reviewing his 320 cases of subclavian vein thrombosis, gave its name as Paget-Schroetter Syndrome. We report below a case of Paget-Schroetter syndrome.
A twenty seven year old male labourer was admitted with prominent veins on the right side of the chest since a period of two years. It started with the patient having to carry a heavy weight on his right shoulder after which he developed painful swelling of the right arm; it was also associated with fever. After a. few days, the patient noticed dilated, prominent veins on the chest. There was no cough, chest pain or breathlessness. There was no wound of obvious injury of the right hand. The patient was non-diabetic, non-hypertensive and nonsmoker.
The pain and swelling subsided within a few days of treatment but the prominent veins had persisted till now; veins became more prominent when the patient had to bend down or lift some heavy weight.
On examination, his right radial pulse rate was 75/minute, regular, and had good volume; all peripheral pulsations were well felt. B.P. in the right upper limb was 120/80 mm Hg. There was no lymphadenopathy or Horner's syndrome. There were dilated engorged veins on the anterior chest wall mainly on the right side and extending to the neck, the direction of flow being below upwards towards the neck [Fig. 1]. The examination of respiratory, cardiovascular and abdominal systems was within normal limits.
Routine investigations, and X-ray of the chest were within normal limits.
Venous angiogram of the right upper extremity showed non-visualisation of the subclavian and a part of the axillary veins. Extensive collaterals bypassing the obliterated segment and draining into the superior versa cava and jugular veins were seen [Fig. 2]
As the disease was two years old, and there was no evidence of active extension of thrombus or phlebitis as evident by absence of signs of inflammation and normal ESR, anticoagulants, and thrombolytic agents were not tried. The patient was referred to the thoracic surgeon for further management.
The process of axillary vein thrombosis occurring in otherwise normal individuals has been termed the "Paget-Schroetter Syndrome.[4]" The varied causes which can initiate the disease have encouraged to coin different terms like "idiopathic[6]; traumatic[1]; spontaneous[3]; effort[5] or strain[7] and the subclavian vein thrombosis[10]. The most common cause is over streaching and contusion of the subclavian vein between the clavicale and the first rib, during an unusual exercise of arm e.g., distempering a ceiling. The damaged endothelium during this process initiates the thrombus formation, which ultimately leads to obliteration of the subclavian vein. Apart from trauma, the filariasis has been implicated in some cases in tropics.[2], [8]
The thrombosis results in painful congestion and oedema of the arm; but as the collaterals develop, the symptoms subside.
The extent of thrombosis can be limited if anticoagulants are given in early stage. Fibrinolytic therapy may restore the circulation if given within two or three days.[13] Corticosteroids and antifilarial drugs have been tried in some cases with favourable results.[12] If there are large collateral veins between the internal jugular and subclavian veins which also pass between the clavicle and the first rib, these collaterals can also be obliterated by hyper-extension of the shoulder. The constriction can be relieved by resection of the clavicle or the first rib.
| 1. | Anderson, O.: Venography in a case of so-called traumatic thrombosis of axillary vein. Acta. Radiologica, 19: 126. 1936. Quoted by Phelan and Crompton (1959).[10]  |
| 2. | Fernando, D. P. A.: A case of Mondor's disease with a probable filarial etiology. Ceylon Med. J., 16: 114-118, 1971. |
| 3. | Ffrench, G. E.: Spontaneous thormbosis of axillary vein. Brit. Mel. J., 2: 277, 1944. |
| 4. | Hughes, E. S. R.: Venous obstruction in upper extremity. Brit. J. Surg., 36: 155-163, 1949. |
| 5. | Kleinsasser, L.: "Effort" thrombosis of axillary and subclavian veins. Analysis of 16 personal cases and 56 cases collected from the literature. Arch. Surg., 59: 258-274,1949. |
| 6. | Marks, J.: Anticoagulant therapy in idiopathic occlusion of axillary vein. Brit. Med. J., 1: 11-13, 1956. |
| 7. | Matas, R.: On the so-callel primary thrombosis of axillary vein caused by strain. Report of a case with comments on diagnosis, pathology and treatment of this lesion in its medicolegal retations. Amer. J. Surg., 24: 642-666, 1934. |
| 8. | Nagaratnam, N., Fernando, D. G. S., Deen, M. F. O., Kulasegaran, V, and Ismail, M. M.: Benign obstruction of subclavian vein probably due to filariasis. Brit. J. Surg., 63: 379-380, 1976. |
| 9. | Paget, J.: "Clinical Lectures and Essays". London, 1975. Quoted by Hughes (1949).[4] |
| 10. | Phelan, J. T. and Crompton, C. W.: So-called primary venous obstruction in upper extremity. Paget-Schrotter's syndrome. Circulation, 19: 350-354, 1959. |
| 11. | Schrotter, L.: "Handbuch der Pathologie and Therapic" (Nothaegel). Holder, 1884. Quoted by Hughes (1949).[4] |
| 12. | Schwartz, S. I., Shires, G. T., Spencer, F. C. and Storer, E. H.: "Principles of Surgery." 3rd Edition, McGraw Hill Book Company, New York, 1979, p. 992. |
| 13. | Sivashanmugham, R., Gopalan, V., Sukumar, P., Ramamurthy, A., Prasad, P. V, S. and Gunasekaran, R.: Paget-Schrotter syndrome-A case report. Ind. Heart J., 34: 177-179, 1982. |
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