Thrombosis of the subclavian vein (Paget–von Schrötter syndrome) is an uncommon condition, typically occurring in young patients following exercise and compression injury to the subclavian or axillary vein from a narrow thoracic outlet (effort thrombosis). Pain, tightness, and arm swelling are manifest within a day. Pitting edema develops in the fingers, hand, and forearm. There is no arterial insufficiency, and the pulses are palpable. This syndrome is separate from iatrogenic upper extremity thrombosis, generally as a result of vascular access catheters. There is a 15% risk of developing pulmonary embolism from thrombosis of upper extremity veins; however, large or fatal emboli are very rare. Ultrasound has become the screening test of choice. Superior vena cava syndrome, upper extremity trauma, heart failure, angioedema, and lymphatic obstruction are in the differential.
Management and Disposition
Treatment consists of hospital admission, elevation, local heat, analgesia, and anticoagulation for patients presenting with long-term thrombosis. In cases of acute thrombosis (within 5 days of symptom onset), thrombolysis with direct catheter infusion of thrombolytic agents or mechanical clot retrieval may be considered. Surgical thrombectomy has also been employed. In cases of effort-dependent thrombosis, operative correction of anatomic abnormalities should be accomplished to prevent long-term morbidity.
Swelling of the neck and face may signify thrombosis or compression of the superior vena cava.
The superficial veins in the upper extremity are often distended and do not collapse when the arm is elevated.
There is a greater incidence of subclavian vein thrombosis in men and in the right arm.
Ultrasound may be limited in visualizing nonocclusive mural thrombi or those located in the proximal subclavian or innominate veins. In these situations, a CT venogram should be considered.
Subclavian Vein Thrombosis. Left subclavian vein thrombosis manifested by swelling of the upper extremity. (Photo contributor: Frank Birinyi, MD.)
Subclavian Vein Thrombosis. Diffuse arm swelling and dilated superficial veins. Note that the veins remain dilated even when the arm is elevated. (Photo contributor: Robert Tubbs, MD.)